Current through Register Vol. 42, No. 11, August 30, 2024
(1)
The hospital shall have a medical record service that has administrative
responsibility for medical records. A medical record shall be maintained for
every individual evaluated or treated in the hospital.
(2) Organization and staffing. The
organization of the medical record service shall be appropriate to the scope
and complexity of the services performed. The hospital shall employ adequate
personnel to ensure prompt completion, filing, and retrieval of
records.
(3) Form and retention of
record. The hospital shall maintain a medical record for each inpatient and
outpatient. Medical records shall be accurately written, promptly completed,
properly filed and retained, and accessible. The hospital shall use a system of
author identification and record maintenance that ensures the integrity of the
authentication and protects the security of all record entries.
(a) Medical records shall be retained in
their original or legally reproduced form for a period of at least five years.
In the case of minor patients, records shall be retained for at least five
years after the patient has reached the age of majority.
(b) The hospital shall have a system of
coding and indexing medical records. The system shall allow for timely
retrieval by diagnosis and procedure, in order to support medical care
evaluation studies.
(c) The
hospital shall have a procedure for ensuring the confidentiality of patient
records. Information from or copies of records may be released only to
authorized individuals, and the hospital shall ensure that unauthorized
individuals cannot gain access to or alter patient records. Original medical
records shall be released by the hospital only in accordance with federal or
state laws, court orders, or subpoenas.
(4) Content of record. The medical record
shall contain information to justify admission and continued hospitalization,
support the diagnosis, and describe the patient's progress and response to
medications and services.
(a) All patient
medical record entries shall be legible, complete, dated, timed, and
authenticated in written or electronic form by the person responsible for
providing or evaluating the service provided, consistent with hospital policies
and procedures.
1. All orders, including
verbal orders, shall be dated, timed, and authenticated promptly by the
ordering practitioner, except as noted below.
2. All orders, including verbal orders, shall
be dated, timed, and authenticated by the ordering practitioner or another
practitioner who is responsible for the care of the patient and authorized to
write orders by hospital policy.
3.
All verbal orders must be authenticated within such time period as provided by
hospital policy, but no more than 30 days following entry of the
order.
(b) All records
shall document the following, as appropriate:
1. Evidence of:
(i) A medical history and physical
examination completed and documented no more than 30 days before or 24 hours
after admission or registration, but prior to surgery or a procedure requiring
anesthesia services. The medical history and physical examination shall be
placed in the patient's medical record within 24 hours after admission or
registration, but prior to surgery or a procedure requiring anesthesia
services.
(ii) An updated
examination of the patient, including any changes in the patient's condition,
when the medical history and physical examination are completed within 30 days
before admission or registration. Documentation of the updated examination
shall be placed in the patient's medical record within 24 hours after admission
or registration, but prior to surgery or a procedure requiring anesthesia
services.
2. Admitting
diagnosis.
3. Results of all
consultative evaluations of the patient and appropriate findings by clinical
and other staff involved in the care of the patient.
4. Documentation of complications, hospital
acquired infections, and unfavorable reactions to drugs and
anesthesia.
5. Properly executed
informed consent forms for procedures and treatments specified by the medical
staff.
6. All practitioners'
orders, nursing notes, reports of treatment, medication records, radiology, and
laboratory reports, and vital signs and other information necessary to monitor
the patient's condition.
7.
Discharge summary with outcome of hospitalization, disposition of case, and
provisions for follow-up care.
8.
Final diagnosis with completion of medical records within 30 days following
discharge.
(5) The hospital shall maintain a plan to
transfer all records to another facility in the event the hospital ceases
operation.
Rule .10 was renumbered to .13 as per certification filed
August 24, 2012; effective September 28,
2012.
Author: W.T. Geary, Jr., M.D., Carter
Sims
Statutory Authority:
Code of Ala.
1975, §§
22-21-20, et seq.
