Minnesota Nursing Home Record Retention Rules

Pursuant to Minnesota Administrative Rule 4658.0470 RETENTION, STORAGE, AND RETRIEVAL.

Subpart 1. Retention. A resident’s records must be preserved for a period of at least five years following discharge or death.

Subp. 2. Storage. Space must be provided for the safe and confidential storage of residents’ clinical records. Records of current residents must be stored on site.

Subp. 3. Retrieval. If records of discharged residents are stored off site, policies and procedures must be developed and implemented by clinical record personnel and the nursing home administration for the confidentiality, retention, and timely retrieval of records within one working day. The policies and procedures must specify who is authorized to retrieve a record. Off-site archived copies of clinical databases must be protected against fire, flood, and other emergencies. The policies must address the location and retention of records if the nursing home discontinues operation.

Computerized Record Retention Rules

According to Minnesota Administrative Rule 4658.0475 COMPUTERIZATION.

If a nursing home is converting to an electronic paperless health information management system:

A. policies and procedures must be established and maintained that require password protection of the clinical database;

B. any outside contract for health information management services must include a provision that the company providing the services assumes responsibility for maintaining the confidentiality of all health information within its control;

C. audit trails must be developed for computer applications to determine the source and date of all entries and deletions;

D. backup systems must be implemented and maintained;

E. preventative maintenance must be implemented and maintained;

F. there must be a plan for preparing, securing, and retaining archived copies of computerized clinical databases;

G. procedures must be implemented for preparing and securing daily, weekly, and monthly archived copies of computerized clinical databases; and

H. there must be confidentiality and protection from unauthorized use of active and archived computerized clinical databases.

Common areas of cases I see include:  Falls from Beds, Hoyer Lifts and in the Bathroom; Sexual Abuse; Medication Errors and Others.  STOP ELDER ABUSE AND NEGLECT!

For more information about nursing home clinical record retention requirements or other questions about elder abuse and neglect contact Nursing Home Neglect Attorney Kenneth LaBore for a free consultation at 612-743-9048 or by email at KLaBore@MNnursinghomeneglect.com.