Current through Register Vol. 24-18, September 15, 2024
(1) The licensee
shall establish and maintain an organized clinical record service, consistent
with recognized principles of record management, directed, staffed, and
equipped to:
(a) Ensure timely, complete and
accurate identification, checking, processing, indexing, filing, and retrieval
of records;
(b) Facilitate
compilation, maintenance, analyses, and distribution of patient care
statistics; and
(c) Protect records
from undue deterioration and destruction.
(2) The licensee shall develop and maintain
an individual clinical record for each person receiving care, treatment, or
diagnostic service at the hospital.
(3) The licensee shall ensure prompt entry
and filing of the following data into the clinical record for each period a
patient receives inpatient or outpatient services:
(a) Identifying information;
(b) Assessment and diagnostic data including
history of findings and treatment provided for the dependency for which the
patient is treated in the hospital;
(c) Comprehensive treatment plan;
(d) Authenticated orders for:
(i) Drugs or other therapies;
(ii) Therapeutic diets; and
(iii) Care and treatment, including standing
medical orders used in the care and treatment of the patient, except standing
medical emergency orders;
(e) Significant observations and events in
the patient's clinical treatment;
(f) Any restraint of the patient;
(g) Data bases containing patient
information;
(h) Original reports
or durable, legible, direct copies of original reports, of all patient tests,
diagnostic procedures and examinations performed on or for the
patient;
(i) Description of
therapies administered, including drug therapies;
(j) Nursing services;
(k) Progress notes recorded by the
professional staff responsible for the care of the patient or others
significantly involved in active treatment modalities; and
(l) A discharge plan and discharge
summary.
(4) The
licensee shall ensure each entry includes:
(a) Date;
(b) Time of day;
(c) Authentication by the individual making
the entry; and
(d) Diagnosis,
abbreviations and terminology consistent with:
(i) Fourth edition revised 1994 The
American Psychiatry Association Diagnostic and Statistical Manual of Mental
Disorders; and
(ii)
International Classification of Diseases, 9th edition,
1988.
(5) The licensee shall provide designated
areas, designed to assure confidentiality, for reading, recording, and
maintaining patient clinical records and for patients to review their own
records.
(6) The licensee shall
prevent access to clinical records by unauthorized persons.
(7) The licensee shall retain and preserve:
(a) Each patient's clinical records,
excluding reports on referred outpatient diagnostic services, for:
(i) Adult patients, a minimum of ten years
following the most recent discharge; or
(ii) Patients who are minors at the time of
care, treatment, or diagnosis, a minimum of three years following the patient's
eighteenth birth date, or ten years following the most recent discharge,
whichever is longer;
(b)
Reports on referred outpatient diagnostic services for at least two
years;
(c) A master patient index
card or equivalent for at least the same period of time as the corresponding
clinical records; and
(d) Patients'
clinical records, registers, indexes, and analyses of hospital service in
original form or in photographic form in accordance with the provisions of
chapter 5.46 RCW.
Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040.
95-22-013, § 246-324-200, filed 10/20/95, effective
11/20/95.
