SECTION .2000 – MEDICAL RECORDS

10A NCAC 14F .2001       POLICIES AND PROCEDURES FOR MEDICAL RECORDS

The program shall develop and implement policies and procedures to include at least the following:

(1)           maintenance of a complete, accurate, and organized medical record for each patient admitted to the program;

(2)           confidentiality of records;

(3)           accessibility of medical record information to the patient, program staff, and non-employees; and

(4)           authentication of entries in medical records including hard copy records and those kept in electronic medium such as computerized records.

History Note:        Authority G.S. 131E-169;

Eff. July 1, 2000;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. December 6, 2016.