Sec. 10.07.02.32. Clinical Records

A. Records for all Residents. Records for all residents shall be maintained in accordance with accepted professional standards and practices.

B. Contents of Record. Contents of record shall include:

(1) Identification and summary sheet or sheets including:

(a) Resident’s name;

(b) Social Security number;

(c) Armed forces status;

(d) Citizenship;

(e) Marital status;

(f) Age;

(g) Sex;

(h) Home address; and

(i) Religion;

(2) Names, addresses, and telephone numbers of referral agencies, including:

(a) Hospital from which admitted;

(b) Personal physician;

(c) Dentist;

(d) Parents’ names or next of kin; and

(e) Resident’s representative;

(3) Documentation of the:

(a) Needs of the resident;

(b) Establishment of an appropriate initial and ongoing treatment plan; and

(c) Care and services provided;

(4) Authentication of hospital diagnoses, based on a:

(a) Discharge summary;

(b) Report from the resident’s attending physician; or

(c) Transfer form;

(5) Consent forms when required, such as:

(a) Administration of investigational drugs;

(b) Burial arrangements made in advance;

(c) Release of medical record information; and

(d) Handling of finances;

(6) Medical and social history of the resident;

(7) Report of physical examination;

(8) Diagnostic and therapeutic orders;

(9) Consultation reports;

(10) Observations and progress notes;

(11) Reports of medication administration, treatments, and clinical findings;

(12) Discharge summary including final diagnosis and prognosis;

(13) Assessments done by various disciplines; and

(14) Interdisciplinary care plan.

C. Staffing. An employee of the nursing home shall be designated as the person responsible for the overall supervision of the medical records service. There shall be sufficient support staff to accomplish all medical records functions.

D. Consultation. If the medical records supervisor is not a qualified medical record practitioner, the Department may require that the supervisor receive consultation from a qualified person.

E. Completion of Records and Centralization of Reports.

(1) Current medical records and those of discharged residents shall be completed promptly.

(2) All clinical information pertaining to a resident’s stay shall be centralized in the resident’s medical record.

F. Retention and Preservation of Records.

(1) Medical records shall be retained for a period of at least 5 years from the date of discharge or, in the case of a minor, 3 years after the resident becomes of age or 5 years, whichever is longer.

(2) The nursing home shall maintain and dispose of a resident’s medical records in accordance with Health-General Article, Title 4, Subtitles 3 and 4, Annotated Code of Maryland.

G. Current Records - Location and Facilities. The nursing home shall maintain adequate space and equipment, conveniently located, to provide for efficient processing, reviewing, indexing, filing, and prompt retrieval of medical records.

H. Closed or Inactive Records. Closed or inactive records shall be filed and stored in a safe place, free from fire hazards, which provides for confidentiality and, when necessary, retrieval.

I. Electronic Health Records.

(1) A nursing home that uses electronic health records exclusively or along with a paper-based medical record shall comply with this chapter and all applicable State and federal laws, including laws governing privacy and security of records.

(2) Staff and nursing home-approved practitioners shall be trained in the use of electronic health records.

(3) A nursing home that uses electronic health records shall:

(a) Ensure access to residents as specified in COMAR 10.07.09.08C(13) and (14); and

(b) On request, provide the resident with copies of the resident’s medical records at a reasonable cost and in the resident’s preferred format.

(4) A nursing home shall provide full access to electronic health records in accordance with all applicable laws and regulations to:

(a) Representatives of the Department as set forth in COMAR 10.07.02.07;

(b) An ombudsman as set forth in Human Services Article, §10-905, Annotated Code of Maryland; and

(c) Other legal representatives as set forth in COMAR 10.07.09.08 and authorized by law to obtain access.

(5) A nursing home shall develop a system to ensure that nursing home staff have access to residents’ health records in the event of a failure of the nursing home’s electronic medical record system.