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New Hampshire Code of Administrative Rules He-P §803.19

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“Resident records under the division of public health services regulations”

All nursing homes must maintain records for each patient.  Resident records must contain the following:

  • A copy of the resident’s admission agreement;
  • Identification data;
  • Contact information of the resident’s health provider;
  • Copies of any executed legal orders and directives;
  • The record of the health examination;
  • Written, dated, and signed orders for all medications, treatments and special diets, laboratory services, and consultations;
  • All assessments and care plans and documentation that the resident or the resident’s guardian or agent participated in the development of the care plan;
  • Documentation of informed consent;
  • All admission and progress notes;
  • Documentation of any alteration in the resident’s daily functioning;
  • Documentation of any medical or specialized care;
  • Documentation of any unanticipated accident, death, or unexplained absences;
  • The consent for release of information signed by the resident or the resident’s guardian or agent;
  • Applicable discharge planning and referrals;
  • Transfer or discharge documentation, including notification to the resident or the resident’s guardian or agent of transfer or discharge;
  • Room change documentation, including notification to the resident or the resident’s guardian or agent of room change;
  • The medication record;
  • Documentation of a resident’s refusal of any care or services.

Resident records and information must be kept confidential and disclosed only as permitted by law.  A nursing home must develop a written policy that specifies the method by which release of information from a resident’s record must occur.  Resident records must be safeguarded against loss or unauthorized use or access.  Resident records must be retained for 4 years after discharge, except for records of Medicaid residents which must be retained for 6 years from the date of service or until the resolution of any legal action commenced during the 6 year period, whichever is longer.  If a nursing home ceases operation, it must arrange for storage of and access to resident records.


Current as of June 2015