10A NCAC 13D .2402       PRESERVATION OF MEDICAL RECORDS

(a)  A facility shall keep medical records on file for five years following the discharge of an adult patient.

(b)  Not withstanding Paragraph (c) of this Rule, if the patient is a minor when discharged from the nursing facility, then the records shall be kept on file until his or her 19th birthday and for the timeframe specified in G.S. 1-17(b) for commencement of an action on behalf of a minor.

(c)  If a facility discontinues operation, the licensee shall inform the Division of Health Service Regulation where its records are stored. Records shall be stored with a business offering medical record storage and retrieval services for five years after the closure date.

(d)  All medical records are confidential. The facility shall be compliant with 42 CFR Parts 160,162 and 164 of the Health Insurance Portability and Accountability Act.

(e)  At the time of the inspection, the facility shall inform the surveyor of the name of any patient who has denied the Department access to his or her medical record pursuant to G.S. 131E-105.

 

History Note:        Authority G.S. 131E‑104; 131E-105;

Eff. January 1, 1996.

Amended Eff. November 1, 2014.