Current through Vol. 41, No. 13, March 15, 2024
(a)
General. The EH shall have medical record services that ensure a
medical record is maintained for every patient evaluated or treated in the
facility. Medical record services shall be appropriate to the scope and
complexity of the services performed and shall ensure prompt completion,
filing, and retrieval of records. In general, services such as transcription,
computer indexing and coding, and electronic storage may be performed off-site
as a contracted service as long as the medical record remains under the control
of the EH. The EH shall ensure that medical records maintained by a contracted
service remain confidential and can be immediately accessed by EH
staff.
(b)
Reports to
agencies and the Department. The EH shall comply with all requirements
specified in OAC
310:667-19-2(a)
regarding the reports made to agencies and the Department.
(c)
Content. The medical record
shall contain information to justify patient admission and treatment, support
the diagnosis, and describe the patient's progress and response to treatment
and services received. All entries shall be legible and complete, and shall be
authenticated and dated promptly by the person, identified by name and
discipline, who is responsible for ordering, providing or evaluating the
service furnished.
(1) The author of each
entry shall be identified and shall authenticate their entry. Authentication
may include written signatures or computerized or electronic entries. If
computerized or electronic authentications are used, the EH shall comply with
all requirements specified at OAC
310:667-19-10(e).
Telephone or verbal orders shall be authenticated by the physician or
practitioner giving the order or meet the requirements at OAC
310:667-19-2(c)(4).
The person taking the telephone or verbal order shall read the order back to
the physician or practitioner to ensure it was correctly understood and verify
on the order the fact that the order was read back. Each facility, within its
own procedures and protocols, shall establish a verification process to be
placed on orders to demonstrate that the order was read back to the
physician.Reports of history and physical examinations and discharge summaries
shall be authenticated by the authorized physician or practitioner who
performed the examination or produced the summary or meet the requirements at
OAC
310:667-19-10(e)
if authenticated by another physician or practitioner. Signature stamps may be
used to authenticate entries in the medical record provided the requirements at
OAC
310:667-19-10(d)
are met.
(2) All inpatient records
shall document the following as appropriate:
(A) Patient identifying information including
individuals to be contacted in case of an emergency.
(B) Evidence of a physical examination,
including a health history, performed not more than thirty (30) days prior to
admission or within forty-eight (48) hours after admission. The history and
physical examination shall be completed, signed and placed in the record within
48 hours of admission.
(C)
Admitting diagnosis.
(D) Results of
all consultative evaluations of the patient and appropriate findings by
clinical and other staff involved in the care of the patient.
(E) Documentation of complications, hospital
acquired infections, and unfavorable reactions to any drug or
biological.
(F) Properly executed
informed consent forms for procedures and treatments performed. The medical and
professional staff shall establish which procedures or treatments require
informed consent consistent with Federal and State law.
(G) All physicians' and practitioners'
orders, nursing notes, reports of treatment, medication records, diagnostic
reports, vital signs and other information necessary to monitor the patient's
condition.
(H) Discharge summary
with outcome of hospitalization, disposition of case, medications at the time
of discharge, and provisions for follow-up care.
(I) Reports. All reports and records shall be
completed and filed within a period consistent with good medical practice and
not longer than thirty (30) days following discharge.
(J) Final diagnosis.
(d)
Maintenance of
records. The EH shall maintain a medical record for each emergency,
stabilization, or observational patient. Medical records shall be accurately
written, promptly completed, properly filed and retained, and accessible. The
EH shall use a system of author identification and record maintenance that
ensures the integrity of the authentication and protects the security of all
record entries.
(1) Medical records shall be
retained at least five (5) years after the date the patient was last seen or at
least of three (3) years after the date of the patient's death. Records of
minors shall be retained three (3) years past the age of majority. Medical
records may be maintained in their original form or may be preserved by other
means as specified by OAC
310:667-19-14(b).
(2) The EH shall have, or provide, a system
of coding and indexing medical records. The system shall allow for timely
retrieval by diagnosis and procedure, in order to support medical care
evaluation studies.
(3) Medical
records shall be confidentially maintained. Information from, or copies of,
records shall be released only to authorized individuals in accordance with
state law, and the EH shall ensure that unauthorized individuals cannot gain
access to, or alter medical records. Original medical records shall be released
only in accordance with federal or state laws or by court order.
(4) Facsimile copies shall be acceptable as
any portion of the medical record. If the facsimile is transmitted on thermal
paper, that paper shall be photocopied to preserve its integrity in the record.
Facsimile copies shall be considered the same as original copies.
(5) In the event of closure of the EH, the EH
shall inform the Department of the disposition of the patient medical records.
Disposition shall be in a manner to protect the integrity of the information
contained in the medical record. These records shall be retained and disposed
of as specified by OAC
310:667-19-14(b)(4).
Added at 20 Ok Reg 1664, eff 6-12-03; Amended
at 21 Ok Reg 2785, eff 7-12-04; Amended at 24 Ok Reg 1189, eff 4-2-07
(emergency); Amended at 25 Ok Reg 2472, eff 7-11-08; Amended at 30 Ok Reg 1966,
eff 7-25-13
