Nev. Admin. Code § 449.379 - Medical records
1. A hospital shall
maintain a medical record for each person evaluated or treated in the
hospital.
2. The organization of
the medical records service at the hospital must be appropriate to the scope
and complexity of the services performed at the hospital. A hospital shall
employ adequate personnel to ensure prompt completion, filing and retrieval of
the medical records.
3. Medical
records must be accurately written, promptly completed, properly filed and
retained, and accessible. A hospital shall use a system for author
identification and record maintenance that ensures the integrity of the
authentication of the record and protects the security of all entries to a
medical record.
4. Except as
otherwise provided in this subsection, medical records must be retained in
their original form or in a legally reproduced form for at least 5 years. The
medical staff may identify specific items in a medical record that must be kept
for at least 10 years. The hospital shall have a system for coding and indexing
its medical records. The system must allow for the timely retrieval of
information by diagnosis and procedure to support studies evaluating the
medical care provided at the hospital.
5. A hospital must have a procedure for
ensuring the confidentiality of the medical records of its patients.
Information from or copies of medical records may be released only to
authorized persons, and the hospital shall ensure that unauthorized persons
cannot gain access to or alter the medical records of its patients. Original
medical records may be released by the hospital only in accordance with state
or federal law, court orders or subpoenas.
6. A medical record must include information:
(a) Demonstrating the justification for the
admission and continued hospitalization of a patient;
(b) Supporting the diagnosis of the patient;
and
(c) Describing the progress of
the patient and his or her response to the medications and services received
during his or her hospitalization.
7. All entries to a medical record must be
legible and complete, and authenticated and dated promptly by the person who is
responsible for ordering, providing or evaluating the service provided. In
authenticating a medical record, the person shall include his or her name and
discipline. Authentication may include the signature or written initials of the
person or a computer entry by the person.
8. All medical records must document the
following information, as appropriate:
(a)
Evidence that a physical examination, including a history of the health of the
patient, was performed on the patient not more than 7 days before or more than
48 hours after his or her admission into the hospital.
(b) The diagnosis of the patient at the time
of admission.
(c) The results of
all consultative evaluations of the patient and the appropriate findings by
clinical and other staff involved in caring for the patient.
(d) Documentation of any complications
suffered by the patient, infections acquired by the patient while in the
hospital and unfavorable reactions by the patient to drugs and anesthesia
administered to the patient.
(e)
Properly executed informed consent for all procedures and treatments specified
by the medical staff, or federal or state law, as requiring written patient
consent.
(f) All orders of
practitioners, nursing notes, reports of treatment, records of medication,
radiology and laboratory reports, vital signs and other information necessary
to monitor the condition of the patient.
(g) A discharge summary that includes a
description of the outcome of the hospitalization, disposition of the case and
the provisions for follow-up care that have been provided to the
patient.
(h) The final diagnosis of
the patient.
9. The
medical record of a patient must be completed not later than 30 days after the
date on which he or she is discharged.
Notes
NRS 449.0302
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