10.07.16.16

.16 Records.

A. The facility shall, either manually or electronically:

(1) Establish a record for a resident; and

(2) 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.

B. The facility shall ensure that residentsí records are:

(1) Maintained in a manner that is consistent with the medical records confidentiality and disclosure requirements of:

(a) Maryland Confidentiality of Medical Records Act, Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and

(b) 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;

(2) Located so that the records are convenient and available to designated staff;

(3) Managed by a designated staff member who is responsible for appropriate records control, including storage, security, and indexing of records; and

(4) Subject to the requirements of confidentiality laws and regulations, are made available to the Department as necessary to carry out required activities.