Utah Administrative Code
Topic - Health
Title R432 - Health Care Facility Licensing
Rule R432-500 - Freestanding Ambulatory Surgical Center Rules
Section R432-500-21 - Medical Records
Universal Citation: UT Admin Code R 432-500-21
Current through Bulletin 2024-06, March 15, 2024
(1) The licensee shall have written policies and procedures that ensure medical records are complete, accurately documented, and systematically organized to facilitate storage and retrieval for staff use.
(2) The licensee shall ensure medical records comply with the following:
(a) a permanent
individual medical record is maintained for each patient admitted;
(b) any entry is permanently typed or
handwritten in ink, and able to be photocopied and stamps are not acceptable
unless a co-signature is present;
(c) each entry is authenticated with the
date, name or identified initials, and title of the person making the
entry;
(d) records are kept current
and conform to medical and professional practice based on the service provided
to the patient;
(e) if utilized, an
automated record system meets the content requirements of this rule;
(f) any records of discharged patients are
completed and filed within a time frame established by written facility policy.
The physician shall complete the medical record; and
(g) each patient's medical record includes
the following:
(i) an admission record that
includes the name, address, and telephone number of the patient, physician and
responsible person and the patient's age and date of admission;
(ii) a current physical examination and
history, including allergies and abnormal drug reactions;
(iii) informed consent signed by the patient
or, if applicable, the patient's representative;
(iv) complete findings and techniques of the
operation;
(v) signed and dated
physician orders for medications and treatments;
(vi) signed and dated nurse's notes that
include vital signs, medications, treatments, and other pertinent
information;
(vii) discharge
summary containing a brief narrative of conditions and diagnoses of the
patient's final disposition, and instructions given to the patient and
responsible person;
(viii) the
pathologist's report of human tissue removed during the surgical procedure, if
any;
(ix) reports of laboratory and
x-ray procedures performed, consultations and any other pre-operative
diagnostic studies; and
(x)
pre-anesthesia evaluation.
(3) The licensee shall ensure medical record retention, storage and release practices comply with the following:
(a) medical records are retained for at least
seven years after the last date of patient care or until a minor reaches age 18
or the age of majority, plus an additional three years;
(b) a new owner retains any patient records
upon change of ownership;
(c)
provision is made for filing, safe storage, security, and easy accessibility of
medical records;
(d) medical record
information is confidential;
(e)
there are written procedures for the use and removal of medical records and the
release of patient information;
(f)
information is disclosed only to authorized persons in accordance with federal
and state laws, and facility policy; and
(g) requests for information identifying the
patient, including photographs, require written consent by the
patient.
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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