N.M. Admin. Code § 8.370.19.25

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.370.19.25 - MEDICAL RECORDS

In accordance with accepted principles of practice, the hospice must establish and maintain a clinical record for every individual receiving care and services. The record must be complete, promptly and accurately documented, readily accessible to staff, and systematically organized to facilitate retrieval.

A. Each clinical record is a comprehensive and chronological compilation of information. Entries are made for all services provided. Entries are made and signed by the staff providing the services. The record includes all services whether furnished directly or under arrangements made by the hospice. Each individual's record shall contain:

(1) the initial and subsequent assessments;

(2) the plan of care;

(3) identification data;

(4) consent, authorization and election forms;

(5) pertinent medical history;

(6) complete documentation of all services and events (including evaluations, treatments, progress notes, etc.).

B. The hospice must safeguard the clinical record against loss, destruction, and unauthorized use.

C. Clinical records shall be retained on each patient for at least 10 years after hospice services have ceased. Clinical records shall be maintained for the requisite period even if the hospice discontinues operations. If the patient is transferred to another health facility, a copy of the record must be made available to the receiving facility. Consultation shall be provided to the receiving facility prior to transfer.

N.M. Admin. Code § 8.370.19.25

Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024