R432-101-33. Medical Records

  (1) The hospital shall comply with the provisions of R432-100-34.

  (2) Contents of the patient record shall describe a patient's physical, social and mental health status at the time of admission, the services provided, the progress made, and a patient's physical, social and mental health status at the time of discharge.

  (a) The patient record identification data recorded on standardized forms shall include the patient's name, home address, date of birth, sex, next of kin, marital status, and date of admission.

  (b) The patient record shall include:

  (i) involuntary commitment status, including relevant legal documents;

  (ii) date the information was gathered, and names and signatures of the staff members gathering the information.

  (c) The patient record shall contain pertinent information on the course of treatment to include:

  (i) signed orders by physicians and other authorized practitioners for medications and treatments;

  (ii) relevant physical examination, medical history, and physical and mental diagnoses using a recognized diagnostic coding system;

  (iii) information on any unusual occurrences, such as treatment complications, accidents, or injuries to or inflicted by the patient, and procedures that place the patient at risk;

  (iv) documentation of patient and family involvement in the treatment program;

  (v) progress notes written by the psychiatrist, psychologist, social worker, nurse, and others significantly involved in active treatment;

  (vi) temperature, pulse, respirations, blood pressure, height, and weight notations, when indicated;

  (vii) reports of laboratory, radiologic, or other diagnostic procedures, and reports of medical or surgical procedures when performed;

  (viii) correspondence with signed and dated notations of telephone calls concerning the patient's treatment;

  (ix) a written plan for discharge including an assessment of patient needs;

  (x) documentation of any instance in which the patient was absent from the hospital without permission;

  (xi) the patient care plan.

  (d) There shall be a discharge summary signed by the attending member of the medical staff and entered into the patient record within 30 calendar days from the date of discharge. In the event a patient dies, the discharge statement shall include a summary of events leading to the death.

  (e) The patient record shall contain evidence of informed consent or the reason it is unattainable.

  (f) The patient record shall contain consent for release of information, the actual date the information was released, and the signature of the staff member who released the information. The patient shall be informed of the release of information as soon as possible.

  (g) The hospital may release pertinent information to personnel responsible for the individual's care without the patient's consent under the following circumstances:

  (i) in a life-threatening situation;

  (ii) when an individual's condition or situation precludes obtaining written consent for release of information;

  (iii) when obtaining written consent for release of information would cause an excessive delay in delivering essential treatment to the individual.