12-4 Vt. Code R. 200:13 - Nursing home clinical records under the Agency of Human Services regulations

“Clinical records under the Agency of Human Services regulations”

Nursing facilities must maintain clinical records on each resident and be retained for eight years from the date of discharge or death or, for a minor, three years after the resident reaches 18 years of age.  Information contained in a nursing facility’s clinical records must be kept confidential.

Clinical records must contain:

• Sufficient information to identify the resident;
• A record of the resident’s assessment;
• The plan of care and services provided;
• The results of any pre-admission screening conduct it by the state; and
• Progress notes.