<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".16" citation="COMAR 10.07.16.16" title_num="10" subtitle_num="07" chapter_num="16" heading="Records.">
  <paragraph num="A.">
    <text>The facility shall, either manually or electronically:</text>
    <paragraph num="(1)">
      <text>Establish a record for a resident; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>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.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>The facility shall ensure that residents’ records are:</text>
    <paragraph num="(1)">
      <text>Maintained in a manner that is consistent with the medical records confidentiality and disclosure requirements of:</text>
      <paragraph num="(a)">
        <text>Maryland Confidentiality of Medical Records Act, Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Relevant federal statutes and regulations, including the Health Insurance Portability Act, 42 U.S.C. §1320D et seq., and implementing regulations at 45 CFR Parts 160 and 164;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Located so that the records are convenient and available to designated staff;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Managed by a designated staff member who is responsible for appropriate records control, including storage, security, and indexing of records; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Subject to the requirements of confidentiality laws and regulations, are made available to the Department as necessary to carry out required activities.</text>
    </paragraph>
  </paragraph>
</regulation>