Utah Administrative Code
Topic - Health
Title R432 - Health Care Facility Licensing
Rule R432-152 - Intermediate Care Facility for Individuals with Intellectual Disabilities
Section R432-152-29 - Client Records
Universal Citation: UT Admin Code R 432-152-29
Current through Bulletin 2024-06, March 15, 2024
(1)
(a) The licensee shall develop and maintain a
record keeping system that includes a separate record for each client with
documentation of the client's health care, active treatment services, social
information and protection of the client's rights.
(b) The licensee shall protect confidential
information contained in the client's records.
(c) The licensee shall develop and implement
policies and procedures governing the release of any client information,
including consent necessary from the client or client's legal
guardian.
(d) The licensee shall
ensure entries into client records shall be legible, dated and signed by the
individual making the entry.
(e)
The licensee shall provide a legend to explain any symbol or abbreviation used
in a client's record.
(f) The
licensee shall ensure each identified residential living unit has available
on-site pertinent information of each client's record.
(g) The licensee shall ensure client records
are complete and systematically organized according to facility policy to
facilitate retrieval and compilation of information.
(2) A Registered Health Information Administrator or a Registered Health Information Technician shall oversee the client record department through employment or consultation. If retained by consultation, onsite visits shall be at least semi-annually and documented through written reports to the administrator.
(3) The licensee shall:
(a) safeguard client records from loss,
defacement, tampering, fires and floods;
(b) protect client records against access by
unauthorized individuals;
(c)
retain client records for at least seven years after the last date of client
care; and
(d) retain records of
minors as follows:
(i) at least two years
after the minor reaches age 18 or the age of majority; and
(ii) a minimum of seven years.
(4)
(a) The licensee shall retain client records
within the facility upon change of ownership;
(b) If a licensee ceases operation, the
licensee shall arrange for appropriate safe storage and prompt retrieval of
client records, client indexes and discharges for the period
specified.
(c) The facility may
arrange storage of client records with another facility or may return client
records to the attending physician who is still in the community.
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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
