Clinical Records - 10-144-110 Me. Code R. § 19.A

Skilled Nursing Facilities must maintain clinical records on every resident.  The records must include all current clinical information pertaining to a resident’s stay, and should be available at the nurse’s station.  The resident’s records need to be kept in the facility at all times, and may be in either paper or electronic format.  All recording must be done in the facility, and must be made immediately available to resident care personnel.  Additionally, all pertinent, non-clinical information (such as address and phone numbers) should be kept current.  All clinical medical records must be kept for 5 years from the date of discharge.  If the patient is a minor, the facility must keep the clinical records for 3 years after a resident reaches legal age.  For closed records, all material pertaining to the patient, including the clinical record, administrative record and care plan should be filed together according to accepted medical record standards.

Additionally, each facility must keep the individual administrative records of each patient on hand at the facility.  Each resident shall have a separate folder which may include resident rights acknowledgments, contracts with the resident, statements of who is responsible for personal needs monies, and records of personal needs monies, including receipts, bank books, or statements and any relevant documentation. These may be filed in inactive files after 12 months.