7 AAC 12.483 - Medical records

(a) In addition to the applicable requirements of 7 AAC 12.770 (Medical Record Service), a frontier extended stay clinic must meet the requirements of this section.

(b) The clinic must maintain its clinical record system in accordance with written policies and procedures, including policies and procedures governing the use and removal of records from the clinic and the conditions for release of information.

(c) A designated member of the clinic staff shall maintain the records and ensure that they are completely and accurately documented, readily accessible, and systematically organized.

(d) For each patient receiving health care services, the clinic shall maintain a record that includes, as applicable,

(1) identification, including the patient's name, age, sex, and address;

(2) evidence of informed consent, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode and the initial disposition;

(3) pertinent history of the patient's current condition;

(4) the time and means by which the patient arrived, including by whom transported;

(5) the diagnosis and treatment given;

(6) reports of physical examinations, diagnostic and laboratory test results, and consultative findings;

(7) the patient's condition on discharge or transfer;

(8) physician's orders, reports of treatment and medication, and other pertinent information necessary to monitor the patient's progress;

(9) final disposition, including instructions given to the patient or the patient's family regarding necessary follow-up care; and

(10) the signature of each physician or other health care professional involved; for purposes of this paragraph, "health care professional" includes a physician or other practitioner, an emergency medical technician, a social worker, or a primary community health aide.

Notes

7 AAC 12.483

Eff. 12/3/2006, Register 180

Authority:AS 47.32.010

AS 47.32.030