59A-4.118. Medical Records

(1) The licensee must designate a full-time employee as being responsible and accountable for the facility’s medical records. (2) Each medical record must contain sufficient information to clearly identify the resident, his or her diagnosis and treatment, and results. (3) Medical records must be retained for a period of five years from the date of discharge. In the case of a minor, the record must be retained for 3 years after a resident reaches legal age under state law.