R432-500-22. Medical Records

(1) Direction.

Medical records shall be complete, accurately documented, and systematically organized to facilitate storage and retrieval for staff use. There shall be written policies and procedures to accomplish these purposes.

(2) Medical Record Organization.

(a) A permanent individual medical record shall be maintained for each patient admitted.

(b) All entries shall be permanent (typed or handwritten legibly in ink) and capable of being photocopied. Stamps are not acceptable unless a co-signature is present. Entries must be authenticated including date, name or identified initials, and title of the person making the entry.

(c) Records shall be kept current and shall conform to good medical and professional practice based on the service provided to the patient. Automated Record Systems may be utilized provided the medical record content maintained meets the requirements as defined within these rules.

(d) All records of discharged patients shall be completed and filed within a time frame established by facility policy. The physician has the responsibility to complete the medical record.

(3) Medical Record Content.

Each patient's medical record shall include the following:

(a) An admission record (face sheet) that includes the name, address, and telephone number of the patient, physician and responsible person and the patient's age and date of admission;

(b) A current physical examination and history, including allergies and abnormal drug reactions;

(c) Informed consent signed by the patient or, if applicable, the patient's representative;

(d) Complete findings and techniques of the operation;

(e) Signed and dated physician orders for drugs and treatments;

(f) Signed and dated nurse's notes regarding care of the patient. Nursing notes shall include vital signs, medications, treatments and other pertinent information;

(g) Discharge summary which contains a brief narrative of conditions and diagnoses of the patient's final disposition, to include instructions given to the patient and responsible person;

(h) The pathologist's report of human tissue removed during the surgical procedure, if any;

(i) Reports of laboratory and x-ray procedures performed, consultations and any other pre-operative diagnostic studies;

(j) Pre-anesthesia evaluation.

(4) Retention and Storage.

(a) Medical records shall be retained for at least seven years after the last date of patient care. Records of minors shall be retained until the minor reaches age 18 or the age of majority plus an additional three years.

(b) All patient records shall be retained by the new owners upon change of ownership.

(c) Provision shall be made for filing, safe storage, security, and easy accessibility of medical records.

(5) Release of Information.

(a) Medical record information shall be confidential.

(i) There shall be written procedures for the use and removal of medical records and the release of patient information.

(ii) Information may be disclosed only to authorized persons in accordance with federal and state laws, and facility policy.

(iii) Requests for information identifying the patient (including photographs) shall require written consent by the patient.

(b) Authorized representatives of the Department may review records to determine compliance with licensure rules and standards.