Utah Administrative Code
Topic - Health
Title R432 - Health Care Facility Licensing
Rule R432-150 - Nursing Care Facility
Section R432-150-24 - Medical Records
Universal Citation: UT Admin Code R 432-150-24
Current through Bulletin 2024-06, March 15, 2024
(1) The licensee shall implement a medical records system to ensure complete and accurate retrieval and compilation of information.
(2)
(a) The
administrator shall designate an employee to be responsible and accountable for
the processing of medical records.
(b) The administrator shall ensure that a
registered record administrator (RRA) or accredited record technician (ART)
directs the medical records department.
(c) If an RRA or ART is not employed at least
part-time, the administrator shall consult with an RRA or ART according to the
needs of the facility, and no less than semi-annually.
(3) The licensee shall ensure resident medical records are:
(a) retained, stored, and
safeguarded from loss, defacement, tampering, and damage from fires and
floods;
(b) protected against
access by unauthorized individuals; and
(c) retained for at least seven years and
medical records of minors are kept until the age of eighteen plus four years,
but in no case less than seven years.
(4) The licensee shall maintain an individual medical record for each resident that contains written documentation of the following:
(a) records made by staff regarding
daily care of the resident;
(b)
informative progress notes by staff to record changes in the resident's
condition and response to care and treatment in accordance with the care
plan;
(c) a pre-admission
screening;
(d) an admission record
with demographic information and resident identification data;
(e) a history and physical examination
up-to-date at the time of the resident's admission;
(f) written and signed informed
consent;
(g) orders by clinical
staff members;
(h) a record of
assessments, including the comprehensive resident assessment, care plan, and
services provided;
(i) nursing
notes;
(j) monthly nursing
summaries;
(k) quarterly resident
assessments;
(l) a record of
medications and treatments administered;
(m) laboratory and radiology
reports;
(n) a discharge summary
for the resident to include a note of condition, instructions given, and
referral as appropriate;
(o) a
service agreement if respite services are provided;
(p) physician treatment orders;
(q) information pertaining to incidents,
accidents, and injuries; and
(r) a
copy of an advanced directive, if a resident has one.
(5) The licensee shall ensure any entries into the medical record are authenticated including date, name or identifier initials, and title of the person making the entries.
(6) The licensee shall ensure resident respite records are maintained within the facility.
Disclaimer: These regulations may not be the most recent version. Utah 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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