Nev. Admin. Code § 449.558

Current through June 11, 2024

Section 449.558 - Preparation and maintenance

1. Each facility shall establish a system for preparing and maintaining a clinical record for each patient of the facility. The system must be developed to ensure that the care provided to each patient of the facility is:

(a) Completely and accurately documented;

(b) Readily available for retrieval by the facility; and

(c) Systematically organized to facilitate the compilation and retrieval of information.

2. If the facility maintains any clinical record on microfilm, optical disc or by any other electronic means, the facility shall ensure that the clinical record is available for review by the Bureau within 48 hours after the facility receives a request for the clinical record from the Bureau.

3. All information concerning the medical history or care provided to or treatment received by a patient at the facility must be:

(a) Maintained in the clinical record of the patient; and

(b) Protected by the facility against theft, loss or damage.

4. Each facility shall establish an area in which to store the clinical records of the facility. The area must be separate from any area of the facility that is used to provide treatment for patients of the facility and must have adequate space for reviewing, dictating, sorting or recording the information included in the clinical records. If a facility uses an optical disc, microfilm or any other electronic means to create or maintain a clinical record, the area used to store the clinical record must have adequate space for transcribing the information created or maintained on the optical disc, microfilm or by any other electronic means. If the facility determines that the clinical record of a patient of the facility is active, the facility shall store the active clinical record at the site of the facility.

5. Each facility shall ensure that:

(a) The clinical record of a patient of the facility remains confidential and is retained in accordance with the provisions of NRS 629.051; and

(b) Each entry or other information that is placed in the clinical record regarding the delivery of care to the patient is not altered without evidence and explanation of that alteration. A signature stamp must not be used to authenticate an entry in the clinical record of a patient of the facility.

6. If a facility determines that a clinical record is inactive, the facility shall store that clinical record. The facility may store the record on microfilm, optical disc or by any other electronic means and may store the clinical record at a location other than at the site of the facility if the facility ensures that:

(a) The clinical record remains secure from unauthorized access at that location; and

(b) The record is readily retrievable for review by the Division.

7. Each clinical record must include:

(a) Information concerning the identity of the patient for whom the clinical record is prepared;

(b) Each written notice provided to the patient at the facility and each written consent obtained from the patient at the facility;

(c) Each order prepared by a physician at the facility concerning the patient;

(d) Each progress note prepared by the facility concerning the patient;

(e) A list that specifies all problems incurred concerning the treatment and care of the patient;

(f) The physical and medical history of the patient;

(g) Each assessment concerning the patient prepared by a registered nurse, social worker or licensed dietitian employed by the facility;

(h) The record of each medication administered by the facility to the patient:

(1) During treatment at the facility; or

(2) For use at his or her residence;

(i) The record of each transfusion received by the patient at the facility;

(j) Each laboratory report prepared or received by the facility concerning the patient;

(k) Each diagnostic study concerning the patient that is ordered by the attending nephrologist;

(l) Each appropriate record of hospitalization;

(m) Each record of consultation with the patient that is requested by the attending nephrologist;

(n) If practicable, the record of creation and revision of access for each dialysis treatment provided to the patient;

(o) Each plan prepared by the facility concerning the care of the patient, including the plan developed for the patient pursuant to the provisions of NAC 449.541 and all amendments to that plan;

(p) Evidence indicating that the facility has complied with the provisions of NAC 449.501 to 449.5795, inclusive, concerning the furnishing of educational materials to the patient;

(q) Each record of the daily treatment received by the patient at the facility; and

(r) A discharge summary, if the patient is discharged from the facility.

8. As used in this section, "progress note" means a note or other written statement that:

(a) Is signed and dated by a member of the staff of a facility; and

(b) Summarizes the facts concerning the care provided to a patient of the facility and the response of the patient to that care for the period specified in the note or other written statement.

Nev. Admin. Code § 449.558

Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R090-12, 12-20-2012

NRS 449.0302