R432-600-21. Medical Records

  (1) Medical records shall be complete, accurately documented, and systematically organized to facilitate storage and retrieval. There shall be written policies and procedures to accomplish these purposes.

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

  (3) All entries shall be permanent and capable of being photocopied. Entries must be authenticated including date, name or identified initials, and title of the person making the entry.

  (4) Records shall be kept for all patients admitted or accepted for treatment and care. Records shall be kept current and shall conform to good medical and professional practice based on the service provided to each patient.

  (5) All records of discharged patients shall be completed and filed as soon as possible or within 30 days of discharge.

  (6) Each patient's medical record shall include the following:

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

  (b) Reports of physical examinations, laboratory tests and X-rays prescribed and completed, including ultrasound reports;

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

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

  (e) Discharge summary which contains a brief narrative of conditions and diagnoses of the patient and final disposition;

  (f) The pathologist's report of human tissue removed during an abortion;

  (g) All information indicated in Section 76-7-313.

  (7) 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 two years. In no case shall the record be retained less than seven years.

  (8) All patient records shall be retained within the clinic upon change of ownership.

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

  (10) Medical record information shall be confidential. There shall be written procedures for the use and removal of medical records and the release of patient information.

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

  (b) Requests for information which may identify the patient (including photographs) shall require the written consent of the patient.