TITLE 16 OCCUPATIONAL
AND PROFESSIONAL LICENSING
CHAPTER 12 NURSING
AND HEALTH CARE RELATED PROVIDERS
PART 10 MANAGEMENT
OF MEDICAL RECORDS
16.12.10.1 ISSUING
AGENCY: New Mexico Board of
Nursing.
[16.12.10.1 NMAC -
N, 02-17-06]
16.12.10.2 SCOPE: This rule governs the use management of
medical records that are created and maintained as part of the practice of a
certified nurse practitioner and clinical nurse specialist.
[16.12.10.2 NMAC -
N, 02-17-06]
16.12.10.3 STATUTORY
AUTHORITY: Section 61-3-1 et seq., authorized the board of nursing
to regulate the practice of nursing in the state.
[16.12.10.3 NMAC -
N, 02-17-06]
16.12.10.4 DURATION: Permanent
[16.12.10.4 NMAC -
N, 02-17-06]
16.12.10.5 EFFECTIVE
DATE: February 17, 2006,
unless a later date is cited at the end of a section.
[16.12.10.5 NMAC -
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16.12.10.6 OBJECTIVE: To
ensure that certified nurse practitioners/clinical nurse specialist provide
copies of medical records to patients; notify their patients of closing,
selling, relocating or leaving a practice and have a system in place for
retention, maintenance and destruction of medical records.
[16.12.10.6 NMAC -
N, 02-17-06]
16.12.10.7 DEFINITIONS: [Reserved]
[16.12.10.7 NMAC -
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16.12.10.8 RELEASE
OF MEDICAL RECORDS: Certified
nurse practitioners/clinical nurse specialists must provide complete copies of
medical records to a patient or to another practitioner in a timely manner when
legally requested to do so by the patient or by a legally designated
representative of the patient.
A. Medical records
may not be withheld because an account is overdue or a bill is owed.
B. A reasonable
charge may be made for the cost of duplicating and mailing medical records. A
reasonable charge is $1.00 per page for the first 25 pages, and $0.10 per page
thereafter. Patients may be charged the cost of reproduction for records
formats other that paper, such as x-rays. Practitioners charging for the cost
of reproduction of medical records should give consideration to the ethical and
professional duties owed to other practitioners and their patients.
[16.12.10.8 NMAC -
N, 02-17-06]
16.12.10.9 CLOSING,
SELLING, RELOCATING OR LEAVING A PRACTICE: Due care should be taken when closing or departing from a practice to
ensure a smooth transition from the current practitioner to the new treating
practitioner. This should occur with a minimum of disruption in the continuity
and quality of medical care being provided to the patient.
A. Active patients
and patients seen within the previous three years should be notified 90 days
before closing, selling, relocating or leaving a practice.
B. Patients should
be notified within 90 days after the death of their practitioner.
C. Notification
should be through an individual letter at the patient’s last known address, and
a notice in newspaper in local practice area (may be several times over a
period of time). Notification should also be sent to the Board.
D. Notification
should include:
(1) responsible entity/agent name of contact
to obtain records or request transfer of records,
Telephone number and
mailing address;
(2) how the records can be obtained or
transferred;
(3) how long the records will be maintained
before they are destroyed;
(4) cost of recovering records/transferring
records; and
(5) whenever possible notification is the
responsibility of the transferring or retiring practitioner.
E. A practitioner
should not withhold patient lists or other information from a departing
practitioner that is necessary for notification of patients.
F. Patients of a
practitioner who leaves a group practice should be notified the practitioner is
leaving, notified of the practitioner new address and offered the opportunity
to have their medical records transferred to the departing practitioner at
his/her new practice.
G. When a practice
is sold, all active patients should be notified that the practitioner is
transferring the practice to another practitioner of entity who will retain
custody of their records and that at their written request the records (or
copies) will be sent to another practitioner or entity of their choice.
H. Failure to
notify patients of closing, selling, relocating or leaving a practice may be a
violation of the nursing practice act and disciplinary action can occur
(16.12.1.9 NMAC).
[16.12.10.9 NMAC -
N, 02-17-06]
16.12.10.10 RETENTION,
MAINTENANCE AND DESTRUCTION OF MEDICAL RECORDS
A. Improper
management of medical records, including failure to maintain timely, accurate,
legible and complete medical records constitutes a violation of 61.3.28 A (6).
B. Destruction of
medical records must be such that confidentiality is maintained. Records should
be shredded or incinerated (where permitted).
C. A log should be
kept of all charts destroyed, including the patient’s name and date of record
destruction.
[16.12.10.10 NMAC -
N, 02-17-06]
HISTORY OF 16.12.10 NMAC:
[RESERVED]