New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 370 - OVERSIGHT OF LICENSED HEALTHCARE FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS
Part 12 - REQUIREMENTS FOR ACUTE CARE, LIMITED SERVICES AND SPECIAL HOSPITALS
Section 8.370.12.30 - MEDICAL RECORDS SERVICES
Universal Citation: 8 NM Admin Code 8.370.12.30
Current through Register Vol. 35, No. 18, September 24, 2024
A. Medical Record: A medical record shall be maintained for every patient admitted for care in the hospital. The record shall be kept confidential and released only in accordance with the Sections 146-1, 14-6-2 NMSA 1978 and, where appropriate, Section 43-1-19 NMSA 1978.
B. Service: The hospital shall have a medical records service with administrative responsibility for all medical records maintained by the hospital.
(1) Confidentiality:
(a) Written consent of the patient or legally
authorized person shall be required for release of medical information to
persons not otherwise authorized to receive this information.
(b) Original medical records may not be
removed from the hospital except by authorized persons who are acting in
accordance with a court order, and where measures are taken to protect the
record from loss, defacement, tampering and unauthorized access.
(2) Preservation: There shall be a
written policy for the preservation of medical records The retention period
shall be for 10 years following the last treatment date of the patient, except
in the case of minor children whose records shall be retained to the age of
majority, plus one year.
(a) Laboratory test
records and reports may be destroyed one year after the date of the test
recorded or reported therein provided that one copy is placed in the patient's
record, or stored electronically in the hospital's information system. The
hospital is responsible for electronic storage.
(b) X-ray films may be destroyed four years
after the date of exposure, if there are in the hospital record written
findings of a radiologist who has read such x-ray films. At anytime after the
third year after the date of exposure, and upon proper identification, the
patient may recover his own x-ray films as may be retained pursuant to this
section. The written radiological findings shall be retained as provided by
these requirements.
(3)
Personnel:
(a) Adequate numbers of personnel
who are qualified to supervise and operate the service shall be
provided.
(b) A registered medical
records administrator or an accredited records technician shall head the
services, except that if such a professionally qualified person is not in
charge of medical records, a consultant who is a registered records
administrator or an accredited records technician shall organize the service,
train the medical records personnel and make at least quarterly visits to the
hospital to evaluate the records and the operation of the service, and prepare
written reports of findings within 30 days.
(c) In this subdivision, "a registered record
administrator" or an "accredited record technician" is an individual who has
successfully completed the examination requirements of the American medical
record association.
(4)
Availability:
(a) The system for identifying
and filing records shall permit prompt retrieval of each patient's medical
records.
(b) A master patient index
shall include at least the patient's full name, sex, birth date and medical
record number or reference to treatment dates.
(c) Filing equipment and space shall be
adequate to maintain the records and facilitate retrieval.
(d) The inpatient, ambulatory care and
emergency records of patients shall be kept in such a way that all patient care
information can be provided for patient care when the patient is admitted to
the hospital, when the patient appears for a pre-scheduled outpatient visit, or
as needed for emergency services.
(e) Pertinent medical record information
obtained from other providers including patient tracking information for
patients admitted during disaster and emergency shall be available to
facilitate continuity of the patient's care.
(f) The original or legally reproduced form
of all clinical information pertaining to a patient's stay shall be filed in
the medical record folder as a unit record. When this is not feasible a system
must be in place to provide prompt retrieval of all medical records when a
patient is admitted.
(5)
Coding and indexing:
(a) Records shall be
coded and indexed according to diagnosis, operation and physician Indexing
shall be kept current within six months from the discharge of the
patient.
(b) Any recognized system
may be used for coding diagnoses, operations and procedures.
(c) The indices shall list all diagnoses for
which the patient was treated during the hospitalization and the operations and
procedures, which were performed during the hospitalization.
C. Medical record contents: The medical record staff shall ensure that each patient's medical records contain:
(1) accurate and
adequate patient identification data;
(2) a concise statement of complaints,
including the chief complaint, which led the patient to seek medical care and
the date of onset and duration of each;
(3) a health history, containing a
description of present illness, past history of illness and pertinent family
and social history to be made part of the record within the first 24 hours
after admission;
(4) a statement
about the results of the physical examination, including all positive and
negative findings resulting from an inventory of systems;
(5) the provisional diagnosis;
(6) all diagnostic and therapeutic
orders;
(7) all clinical
laboratory, x-ray reports and other diagnostic reports;
(8) consultation reports containing a written
opinion by the consultant that reflects, when appropriate, an actual
examination of the patient and the patient's medical records;
(9) except in an emergency, a current,
thorough history and physical work-up shall be recorded in the medical record
of every patient prior to surgery;
(10) an operative report describing
techniques and findings written or dictated immediately after surgery; the
completed operative report is authenticated by the surgeon and filed in the
medical record as soon as possible after surgery or available electronically in
the hospital information system; when the operative report is not placed in the
medical record immediately after surgery, a progress note is entered
immediately;
(11) a post operative
documentation record of the patient's discharge from the post anesthesia care
area;
(12) tissue reports,
including a report of microscopic findings if hospital policies require that
microscopic examination be done; if only microscopic examination is warranted,
a statement that the tissue has been received and a microscopic description of
the findings shall be provided by the laboratory and filed in the medical
record;
(13) progress notes
providing a chronological picture of the patient's progress sufficient to
delineate the course and the results of treatment;
(14) a definitive final diagnosis including
all relevant treatment and operative procedures performed expressed in the
terminology of a recognized system of disease nomenclature;
(15) a discharge summary including the final
diagnosis, the reason for hospitalization, the significant findings, the
procedures performed, the condition of the patient on discharge and any
specific instructions given the patient or family. A final progress note is
acceptable when stay is less than 48 hours and in case of normal newborn
infants and uncomplicated obstetrical deliveries;
(16) autopsy findings when an autopsy is
performed; and
(17) for
comprehensive inpatient programs the following information shall be present as
well: rehabilitation evaluation including medical, psycho-social history and
physical exam; rehabilitation plans including goals for treatment;
documentation of patient care conferences held minimally every two weeks, or as
indicated, by appropriate disciplines involved in the care and treatment of the
patient, in which the patient's treatment and response to rehabilitation
services shall be evaluated and modified as indicated.
D. Authentication: Only members of the hospital staff or other professional personnel authorized by the hospital shall record and authenticate entries in the medical record. Documentation of medical staff participation in the care of the patient shall be evidenced by at least:
(1) the signature on
the patient's health history as the required by medical staff by-laws and
results of his or her physical examination;
(2) periodic progress notes or
countersignatures as defined by the hospital rules and regulations;
(3) the surgeon's signature on the operative
report; and
(4) the signature as
required by medical staff by-laws on the face sheet and discharge
summary.
E. Completion:
(1) Current records
and those on discharged patients shall be completed promptly.
(2) If a patient is readmitted within 30 days
for the same or related condition, there shall be a reference to the previous
history with an interval note, and any pertinent changes in physical findings
shall be recorded.
(3) All records
of discharged patients shall be completed within a reasonable period of time
specified in the medical staff by-laws, but not to exceed 30 days after
discharge, excepting autopsy reports.
F. Maternity patient records:
(1) Prenatal findings: Except in an
emergency, before a maternity patient may be admitted to a hospital, a legible
copy of the prenatal history shall be submitted to the hospital's obstetrical
staff. The prenatal history shall note complication, Rh determination and other
matters essential to adequate care.
(2) Maternal medical record: Each obstetric
patient shall have a complete hospital record, which shall include:
(a) patient identification, prenatal history
and findings;
(b) the labor and
delivery record, including anesthesia;
(c) medicine and treatment sheet, including
nursing notes;
(d) any laboratory
and x-rays reports;
(e) any medical
consultant's notes; and
(f) an
estimate of blood loss.
G. Newborn medical records: Each newborn patient shall have a complete hospital record which shall include:
(1) a record of pertinent material data, type
of labor and delivery, and the condition of the infant at birth;
(2) a record of physical
examinations;
(3) progress sheets
to include medicine, treatment, weights, feeding and temperatures;
and
(4) the notes of any medical
consultant.
H. Fetal death: In the case of a fetal death, the weight and length of the fetus shall be recorded on the delivery record.
I. Authentication of all entries:
(1) Documentation:
(a) All entries in medical records by
hospital staff and medical staff shall be legible, permanently recorded, dated
and authenticated with the name and title of the person making the
entry.
(b) All orders shall be
recorded and authenticated. All verbal and telephone orders shall be
authenticated by the prescribing practitioner, or a practitioner authorized to
sign on behalf of the prescribing physician, in writing within 72
hours.
(c) A rubber stamp
reproduction of a person's signature or an electronic signature may be used
instead of a handwritten signature, if: the stamp is used only by the person
whose signature the stamp replicates, the facility possesses a statement signed
by the person, certifying that only that person(s) shall possess and use the
stamp.
(2) Symbols and
abbreviations: Symbols and abbreviations may be used in medical records if
approved by a written facility policy, which defines the symbols and
abbreviations and controls their use. There shall be only one meaning per
symbol.
Disclaimer: These regulations may not be the most recent version. New Mexico 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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