Code of Colorado Regulations
1000 - Department of Public Health and Environment
1011 - Health Facilities and Emergency Medical Services Division (1011, 1015 Series)
6 CCR 1011-1 Chapter 05 - NURSING CARE FACILITIES
Section 6 CCR 1011-1-5-17 - HEALTH INFORMATION RECORDS

Universal Citation: 1000 CO Code Regs 6 CCR 1011-1-5-17

Current through Register Vol. 47, No. 5, March 10, 2024

17.1 RECORD CONTENT

The facility shall maintain on its premises a health information record for each resident. The record and the resident for which it is maintained shall be identified by a separate, unique number. The record shall contain sufficient information to identify the resident; provide and support resident diagnoses; and include orders for medications, treatments, restorative services, diet, special procedures and resident engagement. It shall include a care plan and discharge plan and indicate in progress notes from all applicable disciplines the resident's progress at appropriate intervals. The components of the record may be kept separately as long as they are readily retrievable.

A) All orders for diagnostic procedures, treatments, and medications shall be entered into the health information record and authenticated and signed by the practitioner, except that orders for dental procedures shall be authenticated and signed by a dentist. All reports of x-ray, laboratory tests, EKG, and other diagnostic tests shall be authenticated by the person or entity submitting them and incorporated into the health information record within two days after receipt by the facility.

B) All entries in the health information record shall be current, dated, and signed or authenticated. The responsibility for completing the health information record rests with the attending practitioner and the facility administrator. Authentication of the health information record shall be accomplished by hand written signature, identifiable initials or digitized electronic signature.

C) A completed health information record shall be maintained on every resident from the time of admission through the time of discharge. All health information records shall contain the following items.
1) Identification and summary sheet (face sheet) that includes:
a) Resident's legal name, preferred name, health information record number social security number, health insurance information, marital status, age, race, home address, date of birth, religion, lifetime occupation, gender and language;

b) Name, address and phone number of attending practitioner(s);

c) Name of medical power of attorney, next of kin and/or resident representative, if known;

d) Date and time of admission and discharge;

e) Place admitted from and discharged to; and f) Admitting diagnosis, final diagnosis(es), condition on discharge and disposition

(2) Medical data that includes:
a) Past medical history;

b) Advance directives and legal authority documentation;

c) Documentation of an initial comprehensive physician visit within 30 days of admission and re-admission based on resident need and at least annually;

d) Informed consents, releases and notifications;

e) Practitioner orders of all medications, treatment, diet, restorative and special procedures;

f) Reports of any special examinations, including laboratory and x-ray reports;

g) Reports of consultations by consulting practitioners, if any;

h) Reports from all consulting persons and agencies, if any;

i) Reports of special treatments, such as physical, occupational, speech or respiratory therapy;

j) Hospice, dialysis, ulcer and/or wound care;

k) Dental reports, if any;

l) Treatment and progress notes written and signed by the practitioner at the time of each visit,

m) Hospital discharge summary sheet and transfer form when applicable; history and physical; surgical report when applicable; and pertinent medication and fluid administration (including names and dates of intravenous medication);

n) Care plans;

o) Interdisciplinary discharge summaries;

p) Physician discharge summary including final diagnoses and, when applicable, cause of death;

q) Transfer records; and r) When applicable, mortician receipt of body and any possessions included.

3) Plans and notes of the social service and resident engagement, including social history, social services assessment/plan, progress notes, resident attendance records, activities assessment/plan and activities progress notes;

4) Nutritional assessments and progress notes of the dietary service;

5) Documentation of accidents or incidents experienced by the resident; and

6) Nursing records, dated and signed by nursing personnel, that include the resident assessment, all medications and treatments administered, special procedures performed, notes of observations, restorative services and the time and circumstances of discharge or death.

17.2 RECORD STORAGE

The facility shall provide a health information record room or other health information record accommodation, supplies and equipment adequate for health information record functions and protection of resident privacy and confidentiality regardless of the form or storage method of records.

A) Health information records shall be maintained and stored safely out of direct access of water, fire and other hazards, for privacy and protection from loss, damage, and unauthorized access or use. Electronically stored records shall be backed up daily and secured from unauthorized access and loss.
1) A privacy officer or other designated staff person shall be appointed to ensure the privacy of health information records in all formats; protect all facility held personal health information; and handle amendments to and accounting of health information records.

B) Custody of health information records shall be the responsibility of the privacy officer or other designated staff person appointed to assess risks and manage the security of health information records in all formats. Current purged and closed paper records must be secured with double locks. Electronic equipment needed for the creation and maintenance of an electronic health information record must be secured from unauthorized access and use and protected from loss. Electronic equipment includes servers, computers, laptops, tablets, pdas, smart phones and cameras.

17.3 RECORD PRESERVATION

All health information records shall be completed no later than 30 calendar days following resident discharge; filed, archived and reproducible for ten years after the date of the last discharge.

17.4 RECORD MAINTENANCE

The facility shall identify and make provisions for the complete and accurate maintenance of the resident health information record to ensure privacy, confidentiality and security standards.

17.5 STAFFING

The facility shall employ health information management staff in sufficient number to meet the needs of the facility. Staff members shall be considered qualified if they meet either of the criteria below.

1) A Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) with either one year of experience in a nursing care facility or, if no experience in a nursing care facility, regular consultations for one year with a qualified RHIA or RHIT, or

2) Dedicated staff member(s) with one year work experience and/or training in health information management and regular consultations from a qualified RHIA or RHIT.

17.6 STAFF RESPONSIBILITIES

Health information staff shall be responsible for all of the following items:

A) The auditing, maintenance, supervision, coding, closing, scanning, filing and providing secure storage of all resident health information records.

B) Providing access to and release of health information per Section 25-1-801, C.R.S.

C) Reporting to the nursing home administrator any irregularities identified during audits, surveys or other investigations by the Department.

D) Obtaining, maintaining and securing current credentialing documentation for all non-employee practitioners, consultants and other licensed professionals who provide services in the facility including, when applicable, the following:
1) DEA license;

2) NPI number;

3) Medicaid provider number;

4) Liability insurance information;

5) Proof of monthly Office of Inspector General (OIG) exclusion list checks and annual enrollment checks through the internet-based Provider Enrollment, Chain and Ownership System (PECOS) as required by federal regulation; and

6) Tuberculosis test results and annual influenza vaccination documentation.

E) Obtaining authentication of signature and initials from each practitioner, consultant and other licensed professional who provides services to residents. For electronic health information records, an electronic signature agreement shall be obtained stating electronic record access and passwords will not be shared.

F) Implementation of health information record disaster plans to meet the needs of the residents during emergencies.

17.7 NURSING CARE FACILITY RECORDS

The facility shall maintain, with current information, the following records:

A) Daily census including current resident room numbers;

B) Admission and discharge registries;

C) Master resident index;

D) Resident number index;

E) Disease index by ICD code; and

F) File of all accident and incident reports including, without limitation, those required by 6 CCR 1011-1, Chapter 2, Part 4.2.

Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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