Section 449.447 - Records of residentsA psychiatric residential treatment facility shall:
1. Maintain a record for each resident evaluated or treated in the psychiatric residential treatment facility.2. Ensure that each record is accurately written, promptly completed, properly filed and retained and accessible. A psychiatric residential treatment facility shall use a system for identification and record maintenance that ensures the integrity of the authentication of the record and protects the security of all entries to the record.3. Ensure that the record of a resident is retained in accordance with the provisions of NRS 629.051.4. Ensure that each record of a resident includes information: (a) Demonstrating the justification for the admission of the resident;(b) Supporting the diagnosis of the resident; and(c) Describing the progress of the resident and his or her response to the medication and services received.5. Ensure all entries to a record of a resident are legible and complete, and authenticated and dated promptly by the person who is responsible for ordering, providing or evaluating the services provided. In authenticating the record, the person shall include his or her name and discipline. Authentication may include the signature or written initials of the person or a computer entry by the person.6. Ensure all records of a resident document the following information, as appropriate: (a) The diagnosis of the resident at the time of admission;(b) The results of all consultative evaluations of the resident and the appropriate findings by clinical and other staff involved in caring for the resident;(c) Documentation of any complications suffered by the resident;(d) All orders of practitioners, reports of treatment, records of medication and other information necessary to monitor the condition of the resident;(e) A discharge summary that includes a description of the outcome of the stay at the psychiatric residential treatment facility, the disposition of the case and the provisions for follow-up care that have been provided to the resident; and(f) The final diagnosis of the resident.7. Ensure that the record of a resident is completed not later than 30 days after the date on which he or she is discharged from the psychiatric residential treatment facility.Nev. Admin. Code § 449.447
Added to NAC by Bd. of Health by R046-14, eff. 10/24/2014