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, the records shall be kept on file until his or her 19th birthday and for the additional time 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.  For five years after a facility discontinues operations, records shall be stored with a business offering medical record storage and retrieval services.

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

(e)  At the time of the inspection, a 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;

Readopted Eff. July 1, 2016.