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Wash. Admin. Code § 388-97-1720

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Content of Nursing Home Clinical Records

Nursing homes must maintain clinical records on each resident.  The records must be complete, accurately documented, readily accessible, and systematically organized.  Nursing homes must safeguard the record against alteration, loss, destruction and unauthorized use, and keep confidential all information contained in the resident’s records.  Each facility should designate an individual who is responsible for the record system and has appropriate training and experience in clinical record management.  Finally, nursing homes must keep a master index with references to each resident that includes the patient’s health record number, as well as, a chronological census register that includes all admissions, discharges, deaths and transfers.  The nursing home must retain records for at least 8 years following discharge or for 3 years after a minor turns 18 or for 10 years after discharge, whichever is longer. 

Related Laws: Wash. Rev. Code § 18.51.300

Current as of June 2015