Current through Bulletin 2024-06, March 15, 2024
(1) The licensee
shall establish a medical records department or service that is responsible for
the administration, custody, and maintenance of medical records.
(a) The hospital administrator shall
establish administrative direction of the medical records department and in
accordance with the organizational structure and policies of the
hospital.
(b) The licensee shall
retain the technical services of either a registered health information
administrator or a registered health information technician through employment
or consultation. If retained by consultation, the individual shall visit at
least quarterly and document visits through written reports to the hospital
administrator.
(2) The
licensee shall provide secure storage, controlled access, prompt retrieval, and
equipment and facilities to review medical records.
(a) The license shall ensure medical records
are available for use or review by:
(i)
members of the medical and professional staff;
(ii) authorized hospital personnel and
agents;
(iii) people authorized by
the patient through a consent form; and
(iv) department representatives to determine
compliance with licensing rules.
(b) Medical records may be stored in multiple
locations if the record can be retrieved or accessed in a reasonable time
period.
(c) If computer terminals
are utilized for patient charting, the licensee shall have policies governing
access and identification codes, security, and information retention.
(d) The licensee shall index a hospital
medical record according to diagnosis, procedure, demographic information, and
physician or licensed health practitioner and ensure the index is current
within six months following discharge of the patient.
(e) Original medical records are the property
of the licensee and shall not be removed from the control of the licensee or
the licensee's agent as defined by policy, except by court order or
subpoena.
(f) The licensee shall
manage medical records for individuals who have received or requested admission
to an alcohol or drug program in accordance with the Code of Federal
Regulations, Title 42, Part 2, Confidentiality of Substance Use Disorder
Patient Records.
(3) The
licensee shall ensure that any medical record entries are legible, complete,
authenticated, and dated by the person responsible for ordering the service,
providing, or evaluating the service, or making the entry. The author shall
review prepared transcriptions of dictated reports, evaluations, and
consultations before authentication.
(a) The
authentication may include written signatures, computer key, or other methods
approved by the governing body and medical staff to identify the name and
discipline of the person making the entry.
(b) Use of computer key or other methods to
identify the author of a medical record entry may not be assignable or
delegated to another person.
(c)
The licensee shall maintain a current list of individuals approved to use the
methods of authentication. Hospital policy shall identify sanctions for the
unauthorized or improper use of computer codes.
(d) Qualified personnel shall accept and
transcribe verbal orders for the care and treatment of the patient and
authenticate them within 30 days of the patient's discharge.
(4) The licensee shall ensure
medical records are organized according to hospital policy and the following:
(a) medical records are reviewed at least
quarterly for completeness, accuracy, and adherence to hospital
policy;
(b) records of discharged
patients are collected, assembled, reviewed for completeness, and authenticated
within 30 days of the patient's discharge;
(c) medical records are retained for at least
seven years and medical records of minors are kept until the age of 18 plus
four years, but in no case less than seven years.
(d) the licensee may destroy medical records
after retaining them for the minimum period of time, and before destroying
medical records, the licensee shall notify the public by publishing a notice in
a newspaper of statewide distribution a minimum of once per week for three
consecutive weeks to allow a former patient to access their records;
(e) the licensee shall permanently retain a
master patient or person index that shall include:
(i) the patient name;
(ii) the medical record number;
(iii) the date of birth;
(iv) the admission and discharge dates;
and
(v) the name of each attending
physician.
(f) if a
licensee ceases operation, the licensee shall provide secure, safe storage and
prompt retrieval of any medical records, patient indexes, and discharges for
the period specified in Subsection
R432-100-34(4)(c);
and
(g) the licensee may arrange
for storage of medical records with another hospital, or an approved medical
record storage facility, or may return patient medical records to the attending
physician if the physician is still in the community.
(5) The licensee shall establish and maintain
a complete medical record for each patient admitted, or who receives hospital
services. Emergency and outpatient medical records shall contain documentation
of the service provided and other pertinent information in accordance with
hospital policy.
(6) The licensee
shall ensure that each medical record contains:
(a) patient identification and demographic
information to include at least the patient's name, address, date of birth,
sex, and emergency contact information;
(b) initial or admitting medical history,
physical and other examinations or evaluations. Recent histories and
examinations may be substituted if updated to include changes that reflect the
patient's current status;
(c)
admitting, secondary, and primary diagnoses;
(d) results of consultative evaluations and
findings by individuals involved in the care of the patient;
(e) documentation of complications, hospital
acquired infections, and unfavorable reactions to medications, treatments, and
anesthesia;
(f) properly executed
informed consent documents for any procedures and treatments ordered for, and
received by, the patient;
(g)
documentation that the facility requested of each admitted person whether the
person has initiated an advanced directive as defined in the Title 75, Chapter
2a, Advance Health Care Directive Act;
(h) practitioner orders, nursing notes,
reports of treatment, medication records, laboratory and radiological reports,
vital signs, and other information that documents the patient condition and
status; and
(i) a discharge summary
including outcome of hospitalization, disposition of case with an autopsy
report when indicated, or provisions for follow-up.
(7) A medical record of a deceased patient
shall contain a completed Inquiry of Anatomical Gift form or a modified
hospital death form that has been approved by the department, as required by
Title 26, Chapter 28, Revised Uniform Anatomical Gift Act.
(8) A medical record of a surgical patient
shall contain:
(a) a pre-operative history and
physical examination;
(b) surgeon's
diagnosis;
(c) an operative report
describing a description of findings;
(d) an anesthesia report including dosage and
duration of any anesthetic and pertinent events during the induction,
maintenance, and emergence from anesthesia;
(e) the technical procedures used;
(f) the specimen removed;
(g) the post-operative diagnosis;
(h) the name of the primary surgeon;
and
(i) assistants written or
dictated by the surgeon within 24 hours after the operation.
(9) A medical record of an
obstetrical patient shall contain:
(a) a
relevant family history;
(b) a
pre-natal examination;
(c) the
length of labor and type of delivery with related notes;
(d) the anesthesia or analgesia
record;
(e) the Rh status and
immune globulin administration when indicated;
(f) a serological test for syphilis;
and
(g) a discharge summary for
complicated deliveries or final progress note for uncomplicated
deliveries.
(10) A
Medical record of a newborn infant shall contain the following documentation in
addition to the requirements for obstetrical medical records:
(a) a copy of the mother's delivery room
record. In adoption cases where the identity of the mother is confidential, the
licensee shall include and access the mother's according to hospital
policy;
(b) the date and hour of
birth;
(c) period of
gestation;
(d) gender;
(e) reactions after birth;
(f) delivery room care;
(g) temperature and weight;
(h) time of first urination; and
(i) number, character, and consistency of
stools;
(j) a record of the
physical examination completed at birth and discharge, record of ophthalmic
prophylaxis, and the identification number of the newborn screening kit,
referred to in Rule R398-1;
(k) the
authorization by the parents, state agency, or court authority if the infant is
discharged to any person other than the infant's parents; and
(l) the record and results of the newborn
hearing screening according to Sections
26B-1-432 and
R398-2-6.
(11) The licensee shall integrate an
emergency department patient medical record into the hospital medical record,
that includes;
(a) time and means of
arrival;
(b) emergency care given
to the patient before arrival;
(c)
history and physical findings;
(d)
lab and x-ray reports;
(e)
diagnosis;
(f) record of treatment;
and
(g) disposition and discharge
instructions.
(12) A
medical -social services patient record shall include:
(a) a medical-social or psychosocial study of
a referred inpatient and outpatient;
(b) the financial status of the
patient;
(c) social therapy and
rehabilitation of the patient;
(d)
an environmental investigation for an attending physician; and
(e) any cooperative activities with community
agencies.
(13) A medical
record of a patient receiving rehabilitation therapy shall include:
(a) a written plan of care appropriate to the
diagnosis and condition;
(b) a
problem list; and
(c) short and
long term goals.
(14) The
medical records department shall maintain records, reports and documentation of
admissions, discharges, and the number of autopsies performed.
(15) The medical records department shall
maintain vital statistic registries for births, deaths, and the number of
operations performed. The medical records department shall report vital
statistics data in accordance with the Title 26B, Chapter 8, Vital Statistics
Act.
