Utah Administrative Code
Topic - Health
Title R432 - Health Care Facility Licensing
Rule R432-200 - Small Health Care Facility - Four to Sixteen Beds
Section R432-200-29 - Medical Records
Universal Citation: UT Admin Code R 432-200-29
Current through Bulletin 2024-06, March 15, 2024
(1) The licensee shall ensure the organization of medical records complies with the following:
(a) records are complete, accurately
documented, and systematically organized to facilitate retrieval and
compilation;
(b) there are written
policies and procedures to accomplish these purposes;
(c) the medical record service is under the
direction of a registered record administrator (RRA) or an accredited record
technician (ART);
(d) if an RRA or
an ART is not employed at least part-time by the licensee, the licensee
consults at least annually with an RRA or ART according to the needs of the
facility; and
(e) a designated
individual oversees day-to-day record keeping.
(2)
(a) The
licensee shall ensure that record retention and storage practices are compliant
with this subsection.
(b) The
licensee shall provide for the filing, safe storage, and easy accessibility of
medical records.
(c) The licensee
shall ensure records and their contents are safeguarded from loss, defacement,
tampering, fires, and floods.
(d)
The licensee shall ensure records are protected against access by unauthorized
individuals.
(e) The licensee shall
ensure records are retained for at least seven years after the last date of
resident care.
(f) The licensee
shall retain records of minors until the minor reaches age 18 or the age of
majority plus an additional two years.
(g) A licensee may not retain a record for
any less than seven years.
(h) The
licensee shall ensure each resident record is retained within the facility upon
change of ownership.
(i) When a
facility ceases operation, the licensee provides appropriate, safe storage and
prompt retrieval of any medical records.
(3)
(a) The
licensee shall ensure that release of information practices are compliant with
this subsection.
(b) The licensee
shall ensure there are written procedures for the use and removal of medical
records and the release of information.
(c) The licensee shall ensure medical records
remain confidential.
(d) The
licensee shall ensure information is only disclosed to authorized individuals
in accordance with federal, state, and local laws.
(e) The licensee shall ensure requests for
other information that may identify the resident, including photographs
requires the written consent of the resident, or guardian if the resident is
judged incompetent.
(4) Authorized representatives of the department may review records to determine compliance with licensure rules and standards.
(5) The licensee may allow rubber-stamp signatures in lieu of the written signature of the physician or licensed practitioner, if the facility retains the signatory's signed statement acknowledging ultimate responsibility for the use of the stamp and specifying the conditions for its use.
(6) The licensee shall ensure that medical records:
(a) are permanently typewritten or hand
written legibly in ink, and capable of being photocopied;
(b) are maintained for each resident admitted
or accepted for treatment and care;
(c) are current and conform to medical and
professional practices based on the service provided to each
resident;
(d) are completed and
filed within 60 days of each client's discharge; and
(e) are authenticated including date, name or
identified initials, and title of each person making each entry.
(7) The licensee shall maintain an individual medical record for each resident that includes:
(a) an admission record face sheet that
identifies the following resident information:
(i) name;
(ii) social security number;
(iii) age at admission;
(iv) birth date;
(v) date of admission;
(vi) name, address, telephone number of
spouse, guardian, authorized representative, person or agency responsible for
the resident; and
(vii) name,
address, and telephone number of the attending physician;
(b) admission and subsequent diagnoses and
any allergies;
(c) reports of
physical examinations signed and dated by the physician;
(d) signed and dated physician orders for
drugs, treatments, and diet; and
(e) signed and dated progress notes that
include:
(i) staff records regarding the daily
care of the resident;
(ii)
informative progress notes that describe the resident's needs and responses to
care and treatment in accordance with the plan of care that are written by any
staff recording changes in the resident's condition;
(iii) documentation of administration of any
as-needed medications and the reason for withholding any scheduled
medications;
(iv) documentation of
use of restraints in accordance with facility policy including type of
restraint, reason for use, time of application, and removal;
(v) documentation of oxygen
administration;
(vi) temperature,
pulse, respiration, blood pressure, height, and weight notations, when
required;
(vii) laboratory reports
of any tests prescribed and completed;
(viii) reports of any x-rays prescribed and
completed;
(ix) records of the
course of any therapeutic treatments;
(x) discharge summary that includes a brief
narrative of conditions and diagnoses of the resident and final
disposition;
(xi) a copy of the
transfer form when the resident is transferred to another health care facility;
and
(xii) resident care
plan.
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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