<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".32" citation="COMAR 10.07.02.32" title_num="10" subtitle_num="07" chapter_num="02" heading="Clinical Records.">
  <paragraph num="A.">
    <text>Records for all Residents. Records for all residents shall be maintained in accordance with accepted professional standards and practices.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Contents of Record. Contents of record shall include:</text>
    <paragraph num="(1)">
      <text>Identification and summary sheet or sheets including:</text>
      <paragraph num="(a)">
        <text>Resident’s name;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Social Security number;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Armed forces status;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Citizenship;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Marital status;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>Age;</text>
      </paragraph>
      <paragraph num="(g)">
        <text>Sex;</text>
      </paragraph>
      <paragraph num="(h)">
        <text>Home address; and</text>
      </paragraph>
      <paragraph num="(i)">
        <text>Religion;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Names, addresses, and telephone numbers of referral agencies, including:</text>
      <paragraph num="(a)">
        <text>Hospital from which admitted;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Personal physician;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Dentist;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Parents’ names or next of kin; and</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Resident’s representative;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Documentation of the:</text>
      <paragraph num="(a)">
        <text>Needs of the resident;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Establishment of an appropriate initial and ongoing treatment plan; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Care and services provided;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Authentication of hospital diagnoses, based on a:</text>
      <paragraph num="(a)">
        <text>Discharge summary;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Report from the resident’s attending physician; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Transfer form;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(5)">
      <text>Consent forms when required, such as:</text>
      <paragraph num="(a)">
        <text>Administration of investigational drugs;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Burial arrangements made in advance;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Release of medical record information; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Handling of finances;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(6)">
      <text>Medical and social history of the resident;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Report of physical examination;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Diagnostic and therapeutic orders;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Consultation reports;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Observations and progress notes;</text>
    </paragraph>
    <paragraph num="(11)">
      <text>Reports of medication administration, treatments, and clinical findings;</text>
    </paragraph>
    <paragraph num="(12)">
      <text>Discharge summary including final diagnosis and prognosis;</text>
    </paragraph>
    <paragraph num="(13)">
      <text>Assessments done by various disciplines; and</text>
    </paragraph>
    <paragraph num="(14)">
      <text>Interdisciplinary care plan.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>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.</text>
  </paragraph>
  <paragraph num="D.">
    <text>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.</text>
  </paragraph>
  <paragraph num="E.">
    <text>Completion of Records and Centralization of Reports.</text>
    <paragraph num="(1)">
      <text>Current medical records and those of discharged residents shall be completed promptly.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>All clinical information pertaining to a resident’s stay shall be centralized in the resident’s medical record.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>Retention and Preservation of Records.</text>
    <paragraph num="(1)">
      <text>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.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>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.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>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.</text>
  </paragraph>
  <paragraph num="H.">
    <text>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.</text>
  </paragraph>
  <paragraph num="I.">
    <text>Electronic Health Records.</text>
    <paragraph num="(1)">
      <text>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.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Staff and nursing home-approved practitioners shall be trained in the use of electronic health records.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>A nursing home that uses electronic health records shall:</text>
      <paragraph num="(a)">
        <text>Ensure access to residents as specified in COMAR 10.07.09.08C(13) and (14); and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>On request, provide the resident with copies of the resident’s medical records at a reasonable cost and in the resident’s preferred format.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>A nursing home shall provide full access to electronic health records in accordance with all applicable laws and regulations to:</text>
      <paragraph num="(a)">
        <text>Representatives of the Department as set forth in COMAR 10.07.02.07;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>An ombudsman as set forth in Human Services Article, §10-905, Annotated Code of Maryland; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Other legal representatives as set forth in COMAR 10.07.09.08 and authorized by law to obtain access.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(5)">
      <text>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.</text>
    </paragraph>
  </paragraph>
</regulation>