Hawaii Administrative Rules
Title 11 - DEPARTMENT OF HEALTH
Subtitle 1 - GENERAL DEPARTMENTAL PROVISIONS
Chapter 95 - FREESTANDING SURGICAL OUTPATIENT FACILITIES
Section 11-95-20 - Medical records
Universal Citation: HI Admin Rules 11-95-20
Current through February, 2024
(a) There shall be available sufficient, appropriate qualified staff and necessary supporting personnel to facilitate the accurate processing, checking, indexing, filing, and prompt retrieval of records and record data.
(b) All patient records shall be considered confidential and the property of the facility which shall secure them against loss, destruction, defacement, tampering, or use by unauthorized persons.
(c) Patient records shall contain, but not necessarily be limited to, the following information:
(1) Prior to surgery, the patient record
shall contain the following:
(A) Sufficient
history, physical examination, x-ray and laboratory data to support the
admitting diagnosis and the decision to carry out the proposed
procedure;
(B) Sufficient history,
physical examination, and laboratory data to support the decision as to which
anesthetic techniques and medications are to be used during the
procedure;
(C) Results of all
pertinent consultation reports, laboratory and x-ray reports shall be recorded
on the chart by the patient's physician. Originals or photocopies of the
originals shall be on the chart within forty-eight hours of admission to the
facility;
(D) Documentation that
sufficient attention has been given to:
(i)
Preventing and preparing for the customary complications of the proposed
surgical procedure and the proposed anesthetic procedure;
(ii) Preventing and preparing for any special
hazards confronting a particular patient;
(E) An informed consent form shall be signed
by the patient or the patient's guardian, or patient's parents, and be filed in
the chart;
(2) Within
forty-eight hours following surgery, the patient's record shall contain:
(A) An operative note which shall clearly
indicate what was found and what was done;
(B) An anesthetic note which shall specify
the anesthetic techniques and medications used, as well as dosages of the
medications. It shall also contain the result of appropriate physiological
monitoring during the anesthetic induction, maintenance and recovery period. A
record of any untoward development during this period shall also be
noted;
(C) All medications given to
or taken by the patient shall be properly recorded in respect to time given,
dose, and any response noted;
(3) A discharge note including the final
diagnosis at the time of discharge;
(4) A copy of the discharge document required
in section
11-95-25(d).
(d) A daily log with monthly summaries of all procedures performed and the disposition of all patients shall be kept by the facility.
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