New Hampshire Code of Administrative Rules He-P §803.19

“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.