Resident record services, N.D. Admin Code 33-07-03.2-17

Resident record services
 
Requires licensed nursing facilities to maintain confidential records for all residents. Grants residents the right to view and authorize disclosure of their records. Permits removal of resident records from the facility only pursuant to a court order or subpoena. Establishes standards for the time of resident record maintenance (e.g., at least 10 years following the date on which a resident is discharged). Specifies the content that facilities must include in each resident record (e.g., diagnosis, family history, lab reports, plan of care, etc.). Requires the authentication of resident record entries by the person that made the entry. Permits the use of electronic signatures for authentication so long as the facility’s governing body adopts an appropriate electronic signature policy that addresses the safeguarding of confidentiality and record accuracy.