Current through Register Vol. 43, No. 39, September 26, 2024
(a) General
provisions. Each hospital shall maintain medical records for each patient
admitted for care. The records shall be documented and readily retrievable by
authorized persons.
(b)
Organization and staffing.
(1) Each hospital
shall have a medical records service that is directed, staffed, and equipped to
enable the accurate processing, indexing, and filing of all medical records.
The medical records service shall be under the direction of a person who is a
registered health information administrator or a registered health information
technician as certified by the American health information management
association, or who meets the educational or training requirements for this
certification.
(2) If the
employment of a full-time registered health information administrator or
registered health information technician is impossible, the hospital shall
employ a registered records administrator or an accredited records technician
on a part-time consultant basis. The consultant shall organize the department,
train full-time personnel, and make periodic visits to evaluate the records.
There shall be a written contract between the hospital and the consultant that
specifies the consultant's duties and responsibilities.
(3) At least one full-time employee shall
provide regular medical records service.
(c) Facilities. The medical records
department shall be properly equipped to enable its personnel to function in an
effective manner and to maintain medical records so that the records are
readily accessible and secure from unauthorized use.
(d) Policies and procedures.
(1) Each medical record shall be kept on file
for 10 years after the date of last discharge of the patient or one year beyond
the date that the minor patient reached the age of majority, whichever is
longer.
(2) If a hospital
discontinues operation, the hospital shall inform the licensing agency of the
location of its records.
(3) A
summary shall be maintained of medical records that are destroyed. This summary
shall be retained on file for at least 25 years and shall include the following
information:
(A) The name, age, and date of
birth of the patient;
(B) the name
of the patient's nearest relative;
(C) the name of the attending and consulting
practitioners;
(D) any surgical
procedure and date, if applicable; and
(E) the final diagnosis.
(4) Medical records may be
microfilmed after completion. If the microfilming is done off the premises, the
hospital shall take precautions to assure the confidentiality and safekeeping
of the records.
(5) Each record
shall be treated as confidential. Only persons authorized by the governing body
shall have access to the records. These persons shall include individuals
designated by the licensing agency for the purpose of verifying compliance with
state or federal statutes or regulations and for disease control investigations
of public health concern.
(6)
Medical records shall be the property of the hospital and shall not be removed
from the hospital premises except as authorized by the governing body of the
hospital or for purposes of litigation when specifically authorized by Kansas
law or appropriate court order.
(e) Contents of medical records. Medical
records shall contain sufficient information to identify the patient clearly,
to justify the diagnosis and treatment, and to document the results accurately.
At a minimum, each record shall include the following:
(1) Notes by authorized house staff members
and individuals who have been granted clinical privileges, consultation
reports, nurses' notes, and entries by designated professional personnel;
(2) findings and results of any
pathological or clinical laboratory examinations, radiology examinations,
medical and surgical treatment, and other diagnostic or therapeutic procedures;
and
(3) provisional diagnosis,
primary and secondary final diagnosis, a clinical resume, and, if appropriate,
necropsy reports.
(f)
Each entry in each record shall be dated and authenticated by the person making
the entry. Verbal orders, including telephone orders, shall include the date
and signature of the person recording them. The prescribing or covering
practitioner shall authenticate the order within 72 hours of the patient's
discharge or 30 days, whichever occurs first. Records of patients discharged
shall be completed within 30 days following discharge.
