north carolina patient care report requirements

Providers of publicly funded services licensed under NC General Statutes 122C (Category A providers), except hospitals, and providers of publicly funded non-licensed periodic or community-based mental health, developmental disabilities and/or substance abuse services (Category B providers) are required to report incidents involving consumers receiving mental health, developmental disabilities and/or substance abuse services.Failure to do so, as required by North Carolina Administrative Code 10A NCAC 27G.0600, may result in DHHS taking administrative action against the provider’s license or authorization to provide services. Hospitals and providers of services licensed under G.S. 131D or G.S. 131E (Category C providers) and individuals certified or licensed in North Carolina to provide only outpatient or day services (Category D providers) are not required to submit incident reports in IRIS.

Full Answer

How do I report a health care provider in North Carolina?

Citizens who want to report a complaint about the care and services provided to a patient/resident/consumer by health care providers licensed by the Division of Health Service Regulation may file a complaintwith the Complaint Intake Unit. The HCPR reporting requirements can be found in N.C. G.S. 131E-256.

Are medical records required in North Carolina?

Documentation The North Carolina Medical Board takes the position that an accurate, current, and complete medical record is an essential component of patient care. Licensees should maintain a medical record for each patient to whom they provide care. The medical record should be legible.

What are the federal reporting requirements for nursing home facilities?

Federal reporting requirements contained in 42 CFR 483.13(PDF,46 KB) requires nursing home facilities to also report allegations made against any employee or contracted staff - licensed or unlicensed - providing services for nursing home residents.

How do I file a complaint against a healthcare provider in NC?

Citizens who want to report a complaint about the care and services provided to a patient/resident/consumer by health care providers licensed by the Division of Health Service Regulation may file a complaintwith the Complaint Intake Unit. The HCPR reporting requirements can be found in N.C. G.S. 131E-256.

When caregiver does not write legibly, should notes be dictated, transcribed, reviewed, and signed within

When the caregiver does not write legibly, notes should be dictated, transcribed, reviewed, and signed within a reasonable time. It is incumbent upon the licensee to ensure that the transcription of notes is accurate (particularly in those instances where dictation software is utilized).

Who has a duty to release a copy of a patient's medical record?

Each licensee has a duty on the request of a patient or the patient’s representative to release a copy of the record in a timely manner to the patient or the patient’s representative, unless the licensee believes that such release would endanger the patient’s life or cause harm to another person.

What is medical record?

The medical record is a chronological document that: • Records pertinent facts about an individual’s health and wellness; • Enables the treating care provider to plan and evaluate treatments or interventions; • Enhances communication between professionals, assuring the patient optimum continuity of care;

Can a licensee charge a reasonable fee for a medical form?

If a form is complex, the licensee may charge a reasonable fee . To prevent misunderstandings, the licensee’s policies about providing copies or summaries of medical records and about completing forms should be made available in writing to patients when the licensee-patient relationship begins.

Can a patient have access to their medical records?

Patients, however, have a substantial right of access to their medical records and a qualified right to amend their medical records pursuant to HIPAA privacy regulations. Medical records are confidential documents and should only be released when permitted by law or with proper written authorization of the patient.

Do medical licensees have to keep medical records?

Retention of Medical Records. Licensees have both a legal and ethical obligation to retain patient medical records. The Board, therefore, recognizes the necessity and importance of a licensee’s proper maintenance, retention, and disposition of medical records.

Address Validation Tool

N.C. CCR Address Validation Tool Data reporters can use this stand-alone application to quickly determine whether an address is valid, using a drill down technique that is superior to the search methods available on commonly used address validation websites.

CCARM - The NC CCR Reporting Manual

Cancer Collection and Reporting Manual (CCARM) - 2022 (6.7 MB PDF) The Cancer Collection and Reporting Manual (CCARM) defines the requirements for reporting to the NC CCR including cases required to be reported, timelines for reporting and specific data items and coding instructions required to describe the cancer.

Data Record Layout

N.C. CCR XML Data Exchange Documentation (290 KB PDF) N.C. CCR XML Data Exchange Requirements – New Case and Modified Records (63 KB Excel)

Edit Metafile

N.C. CCR Edit Metafile (19 MB Zip file) This edit metafile is a modified version of the NAACCR Version 22A Metafile. Vendors must require that all records submitted to the NC CCR pass all edits specified in this metafile. Facilities should use the “Hospital Transmit Edit Set” within the metafile.

Patient Care and Documentation: The Balancing Act

The following disclosure applies to the North Carolina Board of Nursing continuing nursing education article entitled “Patient Care and Documentation: The Balancing Act"

North Carolina Board of Nursing CE Contact Hour Activity Disclosure Statement

The following disclosure applies to the North Carolina Board of Nursing continuing nursing education article entitled “Patient Care and Documentation: The Balancing Act"

What is revision of vague, outdated (pre-HIPAA) language in the NPA?

The updates outlined in Session Law 2019-180 include revision of vague, outdated (pre-HIPAA) language in the NPA, formatting and definition revisions, clarification of the subpoena power and disciplinary authority of the Board, and confidentiality protections for materials gathered by the Board. The Board regulates the practice ...

What is the Nursing Practice Act?

Nursing Practice Act. The Nursing Practice Act regulates the practice of nursing in North Carolina and guides the work of the Board. Article 9. Nurse Practice Act. §§ 90-158 through 90-171.18: Recodified as §§ 90-171.19 through 90-171.47. Updates to the North Carolina Nursing Practice Act (NPA) became effective October 1 st, 2019.

Why is the NPA updated?

Updates to the NPA are made to reflect the current practice of nursing in an ever-changing health care environment and to ensure that the laws governing the regulation of nursing practice in North Carolina facilitate the work of the Board in its legislated mandate to protect the safety of the public.