Md. Code Regs. 10.07.16.16 - Records
A. The facility shall, either manually or electronically:
(1) Establish a record for a resident ; and
(2) Ensure that entries in the record are dated, signed, and include the signer's degree or license , or if the signer has no degree or license , the signer's staff position.
B. The facility shall ensure that residents' records are:
(1) Maintained in a manner that is consistent with the medical records confidentiality and disclosure requirements of:
(a) Maryland Confidentiality of Medical Records Act, Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and
(2) Located so that the records are convenient and available to designated staff ;
(3) Managed by a designated staff member who is responsible for appropriate records control, including storage, security, and indexing of records; and
(4) Subject to the requirements of confidentiality laws and regulations, are made available to the Department as necessary to carry out required activities.
Notes
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