Current through Register Vol. 43, No. 39, September 26, 2024
(a) Each applicant
and each licensee shall maintain an organized recordkeeping system that
provides for identification, security, confidentiality, control, retrieval, and
preservation of all staff member and volunteer records, patient medical
records, and facility information.
(b) Each applicant and each licensee shall
ensure that only individuals authorized by the applicant or licensee have
access to patient medical records.
(c) All records shall be available at the
facility for review by the secretary or the authorized agent of the
secretary.
(d) For staff member and
volunteer records, each applicant and each licensee shall ensure that an
individual record is maintained at the facility. The record shall include all
of the following information:
(1) The staff
member's or volunteer's name, position, title, and the first and last date of
employment or volunteer service;
(2) verification of qualifications, training,
or licensure, if applicable;
(3)
documentation of cardiopulmonary resuscitation certification, if
applicable;
(4) if a physician,
documentation of verification of competence, as required in K.A.R. 28-34-132,
signed and dated by the medical director;
(5) if an individual who performs
ultrasounds, documentation of ultrasound training required in K.A.R. 28-34-132
;
(6) if a surgical assistant,
documentation of training required in K.A.R. 28-34-132 ; and
(7) if a volunteer, documentation of training
required in K.A.R. 28-34-132 .
(e) For patient records, each licensee shall
ensure that an individual record is maintained at the facility for each
patient. The record shall include all of the following information:
(1) Patient identification, including the
following:
(A) Name, address, and date of
birth; and
(B) name and telephone
number of an individual to contact in an emergency;
(2) medical history as required in K.A.R.
28-34-137 ;
(3) the physical
examination required in K.A.R. 28-34-137 ;
(4) laboratory test results required in
K.A.R. 28-34-137 ;
(5) ultrasound
results required in K.A.R. 28-34-137 ;
(6) the physician's estimated gestational age
of the unborn child as required in K.A.R. 28-34-137 ;
(7) each consent form signed by the
patient;
(8) a record of all orders
issued by a physician, physician assistant, or nurse practitioner;
(9) a record of all medical, nursing, and
health-related services provided to the patient;
(10) a record of all adverse drug reactions
as required in K.A.R. 28-34-136 ; and
(11) documentation of the efforts to contact
the patient within 24 hours of the procedure and offer and schedule a follow-up
visit no more than four weeks after the procedure, as required in K.A.R.
28-34-141 .
(f) For
facility records, each applicant and each licensee shall ensure that a record
is maintained for the documentation of the following:
(1) All facility, equipment, and supply
requirements specified in K.A.R. 28-34-133 through 28-34-136 ;
(2) ancillary services documentation required
in K.A.R. 28-34-136 ;
(3) risk
management activities required in K.A.R. 28-34-142 ; and
(4) submission of all reports required in
K.A.R. 28-34-143 .
