Indiana Administrative Code
Title 410 - INDIANA DEPARTMENT OF HEALTH
Article 27 - BIRTHING CENTERS
Rule 7 - Medical Records
Section 7-1 - Medical records; storage; administration
Universal Citation: 410 IN Admin Code 7-1
Current through March 20, 2024
Authority: IC 16-21-1-7; IC 16-21-2-2.5
Affected: IC 16-21-1
Sec. 1.
(a) The birthing center must do the following:
(1)
Create and maintain a medical record on each patient.
(2) Have a written policy that ensures
responsibility for and maintenance of medical records as follows:
(A) The center must establish and implement
the following:
(i) Policies and procedures to
assure that the care and services provided to each patient are appropriately
documented.
(ii) A system to assure
that medical records are readily available in accordance with center policy and
systematically organized to facilitate the compilation and retrieval of
information.
(B) The
policy must provide safeguards to assure protection of the medical records from
the following:
(i) Fire.
(ii) Water.
(iii) Other sources of damage.
(C) All original medical records
or legally reproduced medical records must be maintained by the center for a
period of at least seven (7) years or the applicable statute of limitation,
whichever is longer. Original medical records must be maintained in the center
for at least two (2) years. Records over two (2) years old may be kept off-site
but must be retrievable within forty-eight (48) business hours.
(b) A medical record must be maintained with documentation of service rendered for each patient of the center as follows:
(1) Medical records:
(A) are documented accurately and in a timely
manner;
(B) are readily accessible;
and
(C) permit prompt retrieval of
information.
(2) A unit
record system of filing should be utilized. When this is not practicable, a
system must be established by the center to retrieve, when necessary, all
divergently located record components.
(3) The center shall use a system of author
identification and record maintenance that:
(A) ensures the integrity of the
authentication; and
(B) protects
the security of all record entries.
Each entry must be authenticated in accordance with the center and medical staff policies.
(4) Medical records must be retained in their
original or legally reproduced form as required by federal or state
law.
(5) Plain paper facsimile
orders, reports, and documents are acceptable for inclusion in the medical
record if allowed by the center policies.
(6) The center shall have a system of coding
and indexing medical records that allows for timely retrieval of records by:
(A) identification data;
(B) diagnosis;
(C) treatment rendered;
(D) physician;
(E) condition on discharge; and
(F) transfer to hospital;
in order to support continuous quality assessment and improvement activities.
(7) The center shall ensure the
confidentiality of patient records. The center must develop, implement, and
maintain the following:
(A) A procedure for
releasing information or copies of records only to authorized individuals in
accordance with federal and state laws.
(B) A procedure that ensures that
unauthorized individuals cannot gain access to medical records.
(c) A written or electronic register must be kept of all patients treated that provides the following:
(1) Identification data.
(2) Treatment rendered.
(3) Attending or primary physician.
(4) Medical staff person performing the
delivery.
(5) Condition on
discharge.
(6) Transfers to
hospital facility.
(7) Other data
deemed necessary by the center.
Disclaimer: These regulations may not be the most recent version. Indiana 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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