Current through Register Vol. 50, No. 9, September 20, 2024
A. The facility
shall maintain medical records which include clinical, medical, and
psychosocial information on each resident.
1.
These records must be:
a. complete;
b. accurately documented;
c. readily accessible; and
d. systematically organized.
2. Facilities shall have written
policies and procedures governing access to, duplication of, and dissemination
of information from the resident's personal and medical records.
B. Availability of Records
1. The facility shall make necessary records
available to appropriate state and federal personnel at reasonable times.
Records shall include but shall not be limited to the following:
a. personal property and financial records;
and
b. all medical records
NOTE: This includes records of all treatments, drugs, and
services for which vendor payments have been made, or which are to be made,
under the Medical Assistance Program. This includes the authority for and the
date of administration of such treatment, drugs, or services. The facility
shall provide sufficient documentation to enable DHH to verify that each charge
is due and proper prior to payment.
c. All other records which DHH finds
necessary to determine a facility's compliance with any federal or state law,
rule, or regulation promulgated by the Department of Health and Human Services
(DHHS) or by DHH.
2.
Overall supervisory responsibility for the resident record service is assigned
to a responsible employee of the facility. If the resident record supervisor is
not a qualified medical record practitioner, this person functions with
consultation from a person so qualified minimum consultation time shall not be
less than one hour per quarter.
C. Availability of Medical Records to
Facility Staff. The facility shall ensure that medical records are available to
licensed staff directly involved with the resident's care.
D. Confidentiality. Facilities shall ensure
confidential treatment of personal and medical records, including information
contained in automatic data banks. The written consent of the resident or
his/her legal representative shall be required for the release of information
to any persons not otherwise authorized under law to receive it.
E. Protection of Records. The facility shall
protect records against loss, damage, destruction, and unauthorized
use.
F. Retention of Records. The
facility shall retain records for:
1. in the
case of minors, three years after they become 18 years of age; and
2. six years after the date of
discharge.
G. Components
of Medical Records. Each medical record shall consist of the active medical
chart and the facility medical files or folders.
1. Active Medical Charts
a. The active medical charts shall contain
the following information:
i. three to six
months of current pertinent information relating to the active ongoing medical
care;
ii. physician certification
of each medical assistance admission;
iii. physician recertification that the
resident required the services of the facility;
iv. certification that each plan of care has
been periodically reviewed and revised; and
v. if the facility is aware that an resident
has been interdicted, a statement to this effect shall be noted in a
conspicuous place in the active medical chart.
2. Medical Files. As the active chart becomes
bulky, the outdated information shall be removed and filed in the facility's
medical files or folders.
H. Contents of Medical Records. An organized
active record system shall be maintained for each resident. It shall include
the following identifying information:
1. full
name;
2. home address, including
street address, city, parish, and state;
3. social security number;
4. medical identification number;
5. medicare claim number, if
applicable;
6. marital
status;
7. date of birth;
8. sex;
9. religious preference;
10. birthplace;
11. father's name;
12. mother's maiden name;
13. name, address, and telephone number of
referral agency or hospital;
14.
personal attending physician and alternate, if possible;
15. choices of other service
providers;
16. name and address of
next of kin or other legal representative or sponsor;
17. admitting diagnosis;
18. current diagnosis, including primary and
secondary DSM III diagnosis, if applicable;
19. date of death;
20. cause of death;
21. diagnosis at death;
22. copy of death certificate;
23. disposition of body;
24. name of funeral home, if appropriate;
and
25. any other useful
identifying information.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
46:153.
