175 Neb. Admin. Code, ch. 1, § 008

Current through September 17, 2024

Section 175-1-008 - RECORDKEEPING

The licensee must maintain complete and accurate records which document the operation of the facility or service and the care and treatment provided to the consumer. Records may be created and maintained in written or electronic format, or a combination of both. Records must:

(A) Contain dated, legible and indelible entries;

(B) Ensure entries are dated, timed, and signed by the author;

(C) Be readily accessible, easily retrievable, and systematically organized;

(D) Be transferred to another facility or service, if the consumer is transferred, to assure continuity of care;

(E) Contain the following:

(i) Identification data, including name, date of birth, gender;

(ii) Physical description of the consumer and or a photograph;

(iii) A signed Service Agreement or Consent to Treatment;

(iv) Allergies;

(v) Plan of care and treatment;

(vi) Advanced directives, if available;

(vii) Dates of admission and discharge, including transfer information and a discharge summary, as applicable;

(viii) Medical practitioner's orders, when applicable;

(ix) Name and contact information of the medical practitioner;

(x) Emergency contact information;

(xi) An assessment to determine the mental, physical and psychological ability of the consumer to protect themselves from injury;

(xii) Documentation of all diagnoses, care and treatment provided, and the results or response; and

(xiii) Documentation of education of rights for the consumer.

008.01CONFIDENTIALITY. Records must be kept confidential and available only for use by authorized persons or as otherwise permitted by law. Records must be available for copying and examination by an authorized representative of the Department.

008.02ACCESS TO RECORDS. Records will be released only with the consent of the consumer or their designee or as required by law.

008.03RETENTION AND PRESERVATION. All records for the consumer must be preserved in original, microfilm, electronic, or other similar form. The licensee must retain these records for a minimum of 7 years beginning with each service date, protect the confidentiality of all information contained, regardless of the form or storage method of the records; and safeguard the records against loss, destruction, or unauthorized use.

008.04DESTRUCTION. When a consumer record is destroyed, such destruction must be by shredding, incineration, electronic deletion, or by other similar protective measures in order to preserve the confidentiality of the information in the record. Documentation of record destruction must be maintained permanently.

008.05DISCONTINUATION OF OPERATIONS. When a licensee discontinues operation of a facility or service the licensee must transfer consumer records to the facility or service chosen by the consumer or designee. All records that are not transferred per the consumer or designee, which have not reached the time permitted for destruction of the record, must be stored to assure confidentiality, and the Department must be notified in writing, via email or facsimile, of the address where these records are stored prior to the close of business.

175 Neb. Admin. Code, ch. 1, § 008

Adopted effective 3/12/2023