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 09 - COMMUNITY CLINICS AND COMMUNITY CLINICS AND EMERGENCY CENTERS
Part 10 - HEALTH INFORMATION MANAGEMENT

Universal Citation: 1000 CO Code Regs 10

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

10.1 Each CC shall comply with the requirements of 6 CCR 1011-1, Chapter 2, Part 6, regarding patient access to medical records.

10.2 The CC shall provide sufficient space and equipment for the processing and the safe storage of medical records. Records shall be maintained and stored out of direct access of water, fire, and other hazards to protect them from damage and loss. A records recovery or backup system shall be utilized to ensure that there is no loss of medical records.

10.3 A person knowledgeable in health information management shall be responsible for the proper administration and protection of health information.

10.4 The facility shall store health information in a manner that protects patient privacy and confidentiality and allows for retrieval of records in a timely manner.

10.5 Medical records shall be preserved as original records, in a manner determined by the CC:

(A) For minors, for the period of minority plus ten (10) years (i.e., until the patient is age 28) or ten (10) years after the most recent patient encounter, whichever is later.

(B) For adults, ages eighteen (18) and older, for no less than seven (7) years after the most recent patient care encounter.

10.6 If a CC ceases operation, the CC shall make provision for secure, safe storage and prompt retrieval of all medical records for the period specified in this Part 10.5 (A) and (B).

10.7 A CC that ceases operation must comply with the provisions of 6 CCR 1011-1, Chapter 2, Part 2.14.4.

10.8 After the required time of record preservation, records may be destroyed at the discretion of the CC, in accordance with the CC's record retention policy. The CC shall establish procedures for notification to patients whose records are to be destroyed prior to the destruction of such records.

10.9 General Content of Medical Records

(A) Complete medical records shall be maintained on every patient from the time of registration for services through discharge. All entries into the record shall be dated, timed, and authorized by appropriate personnel.

(B) All diagnostic procedures, treatments, and medications shall be ordered by the provider staff or other authorized licensed practitioners and entered in the medical record. The prompt completion of the medical record shall be the responsibility of the provider staff.

(C) Authorization may be by written signature, identifiable initials, or computer key.

(D) The record shall contain accurate documentation of significant clinical information pertaining to the patient sufficiently detailed and organized in such a manner to enable:
(1) Another provider to assume care of the patient at any time.

(2) Sufficient information for the evaluation of the quality of patient care by the quality management program.

(3) The provider staff to utilize the record to instruct the patient and family members. 10.10 The records of individual patients shall contain, but not be limited to:
(A) A unique medical record identification number, identification data including medical history, physical examination, and risk assessments, including psychosocial information.

(B) Properly executed consent to treat forms, informed consent(s), and advance directives, when applicable.

(C) Reports of physical examinations, vital signs, diagnostic and laboratory test results, reports of all imaging, and consultative reports and findings, if any.

(D) A brief summary of the care encounter and a record of patient education, medications, treatments, procedures, and any other information necessary to monitor the patient's progress. Documentation shall include notation of the instructions given to patients on the date of service.

(E) Documentation of complications, adverse reactions to drugs and/or anesthesia, referrals, and transfers.

(F) Final diagnosis with completion of medical records within (thirty) 30 days following the CC visit.

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.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.