NAC 449.150  Records of clients. 

     1.  Each facility must maintain an organized system for clients’ records.

     2.  Clients’ records must be available to members of the staff who have authority to review such records.

     3.  Clients’ records must be available to representatives of the Division.

     4.  Clients’ records must contain:

     (a) Identification information;

     (b) Past medical and social history;

     (c) Copies of initial and periodic examinations;

     (d) Evaluations and progress notes; and

     (e) A review and any revisions of each plan of treatment.

     5.  There must be an overall plan of treatment stated in quantifiable terms which outlines goals to be accomplished through individually designed activities, therapies and treatments.

     6.  The plan of treatment must state what service or person is responsible for treatment or services to the client.

     7.  Entries must be made describing treatments and services rendered, medications administered, including those that are self-administered, and any symptoms or other indications of illness or injury, including the date, time and action taken regarding each incident.

     8.  Records must be adequately safeguarded against destruction, loss or unauthorized use.

     9.  Records must be retained for at least 5 years following a client’s discharge.

     10.  A discharge plan, as determined by a case management services assessment of the client, must be documented for each client discharged from the facility. The discharge plan must be formulated upon a client’s admission to the facility.