New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter V - Medical Facilities
Subchapter A - Medical Facilities-minimum Standards
Article 2 - Hospitals
Part 405 - Hospitals-Minimum Standards
Section 405.10 - Medical records
Universal Citation: 10 NY Comp Codes Rules and Regs ยง 405.10
Current through Register Vol. 46, No. 39, September 25, 2024
The hospital shall have a department that has administrative responsibility for medical records. An accurate, clear, and comprehensive medical record shall be maintained for every person evaluated or treated as an inpatient, ambulatory patient, emergency patient or outpatient of the hospital.
(a) General requirements.
(1) Medical records
shall be legibly and accurately written, complete, properly filed, retained and
accessible in a manner that does not compromise the security and
confidentiality of the records.
(2)
The hospital shall establish, implement and monitor an effective system of
author identification for medical records and/or medical orders to ensure the
integrity of the authentication and protect the security of all transmissions,
records and record entries. This system shall identify those categories of
practitioners and personnel who are authorized to utilize electronic or
computer authentication systems.
(3) The hospital shall ensure that all
medical records are completed within 30 days following discharge.
(4) Medical records shall be retained in
their original or legally reproduced form for a period of at least six years
from the date of discharge or three years after the patient's age of majority
(18 years), whichever is longer, or at least six years after death.
(5) The hospital shall have a system of
coding and indexing medical records. The system shall allow for timely
retrieval by diagnosis and procedure, in order to support quality assurance
studies.
(6) The hospital shall
ensure the confidentiality of patient records. Original medical records,
information from or copies of records shall be released only to hospital staff
involved in treating the patient and individuals as permitted by Federal and
State laws.
(7) The hospital shall
allow patients and other qualified persons to obtain access to their medical
records and to add brief written statements which challenge the accuracy of the
medical record documentation to become a permanent part of the medical record,
in accordance with the provisions of Part 50 of Chapter II of this Title and
the provisions of Public Health Law, section 18(4).
(b) Content.
(1) The medical record shall contain
information to justify admission and continued hospitalization, support the
diagnosis, and describe the patient's progress and response to medications and
services.
(2) All records shall
document, as appropriate, at least the following:
(i) evidence of a physical examination,
including a health history, performed no more than 30 days prior to admission
or within 24 hours after admission and a statement of the conclusion or
impressions drawn;
(ii) admitting
diagnosis;
(iii) results of all
consultative evaluations of the patient and findings by clinical and other
staff involved in the care of the patient;
(iv) documentation of all complications,
hospital acquired infections, and unfavorable reactions to drugs and
anesthesia;
(v) properly executed
consent forms for procedures and treatments;
(vi) all practitioners' diagnostic and
therapeutic orders, nursing documentation and care plans, reports of treatment,
medication records, radiology, and laboratory reports, vital signs and other
information necessary to monitor the patient's condition;
(vii) discharge summary with outcome of
hospitalization, disposition of case and provisions for follow-up care;
and
(viii) final
diagnosis.
(c) Authentication of medical records, record entries and medical orders.
(1)
Upon completion of ordering or providing or evaluating patient care services,
each such action shall be recorded and promptly entered in the patient medical
record. All entries shall be legible and complete and shall be authenticated by
the person entering, ordering or completing such action. Legible and signed
facsimile orders may be accepted and shall be filed in the patient medical
record.
(2) Written signatures, or
initials and electronic signatures or computer generated signature codes shall
be acceptable as authentication when utilized in accordance with hospital
policy.
(3) Each electronic or
computer entry, order or authentication shall be recorded in the medical record
as to date, time, category of practitioner, mode of transmission and point of
origin.
(4) Safeguards to ensure
security and confidentiality shall include but not be limited to:
(i) the assignment, as appropriate, of a
unique identifier that is assigned in a confidential manner;
(ii) the certification in writing by the
hospital's designee and the user that each identifier assigned is confidential
and is available and accessible only to the person authorized to use the
electronic or computer authentication system;
(iii) policies and procedures to ensure the
security of electronic or computer equipment from unwarranted access;
(iv) policies and procedures that restrict
access to information and data to those individuals who have need, reason and
permission for such access; and
(v)
the implementation of an audit capability to track access by users.
(5) Hospitals shall implement an
ongoing verification process to ensure that electronic communications and
entries are accurate, including but not limited to:
(i) protocols for ensuring that incomplete
entries or reports or documents are not accepted or implemented until reviewed,
completed and verified by the author; and
(ii) a process implemented as part of the
hospital's quality assurance activities that provides for the sampling of
records for review to verify the accuracy and integrity of the
system.
(6) Written
notice from the author shall be required should the author/user wish to
terminate participating in the electronic or computer authentication
system.
(7) The hospital shall have
procedures in place to modify or terminate use of any assigned identifier in
cases of abuse or misuse or if practice privileges are suspended, restricted,
terminated or curtailed or employment or affiliation ends.
(8) The hospital shall implement policies and
procedures regarding the use and authentication of verbal orders, including
telephone orders. Such policies and procedures must:
(i) specify the process for accepting and
documenting such orders;
(ii)
ensure that such orders will be issued only in accordance with applicable scope
of practice provisions for licensed, certified or registered practitioners,
consistent with Federal and State law; and
(iii) specify that such orders must be
authenticated by the prescribing practitioner, or by another practitioner
responsible for the care of the patient and authorized to write such orders and
the time frame for such authentication.
(9) All orders for controlled substances
shall be carried out in accordance with provisions of Part 80 of this
Title.
Disclaimer: These regulations may not be the most recent version. New York 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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