7 AAC 12.770 - Medical record service
(a) Each facility, with the exception of home
health agencies, hospice agencies, intermediate care facilities for the
mentally retarded, and birth centers, must have a medical record service that
complies with the applicable provisions of this section. A frontier extended
stay clinic must comply with (b), (d), (g), and (i) - (k) of this section in
addition to the requirements of
7 AAC 12.483.
(b) A facility must keep records on all
patients admitted or accepted for treatment. The medical records, including
x-ray films, are the property of the facility and are maintained for the
benefit of the patients, the medical staff, and the facility. Medical records
are subject to the requirements of
AS
18.05.042,
7 AAC 43.030, and
7 AAC 43.032. This section does not affect other
statutory or regulatory requirements regarding access to, use of, disclosure
of, confidentiality of, or retention of record contents, or regarding
maintenance of health information in patients' records by health care
providers. A facility must maintain originals or accurate reproductions of the
contents of the originals of all records, including x-rays, consultation
reports, and laboratory reports, in a form that is legible and readily
available
(1) upon request, to the attending
physician or other practitioner responsible for treatment, a member of the
facility's medical staff, or a representative of the department; and
(2) upon the patient's written request, to
another practitioner.
(c) Each in-patient medical record must
include, as appropriate
(1) an identification
sheet which includes the
(A) patient's
name;
(B) medical record
number;
(C) patient's address on
admission;
(D) patient's date of
birth;
(E) patient's sex;
(F) patient's marital status;
(G) patient's religious preference;
(H) date of admission;
(I) name, address, and telephone number of a
contact person;
(J) name of the
patient's attending physician;
(K)
initial diagnostic impression;
(L)
date of discharge and final diagnosis; and
(M) source of payment;
(2) a medical and psychiatric history and
examination record;
(3)
consultation reports, dental records, and reports of special studies;
(4) an order sheet which includes medication,
treatment, and diet orders signed by a physician;
(5) progress notes for each service or
treatment received;
(6) nurses'
notes which must include
(A) an accurate
record of care given;
(B) a record
of pertinent observations and response to treatment including psychosocial and
physical manifestations;
(C) an
assessment at the time of admission;
(D) a discharge plan;
(E) the name, dosage, and time of
administration of a medication or treatment, the route of administration and
site of injection, if other than by oral administration, of a medication, the
patient's response, and the signature of the person who administered the
medication or treatment; and
(F) a
record of any restraint used, showing the duration of usage;
(7) court orders relevant to
involuntary treatment;
(8)
laboratory reports;
(9) x-ray
reports;
(10) consent
forms;
(11) operative report on
in-patient and out-patient surgery including pre-operative and post-operative
diagnosis, description of findings, techniques used, and tissue removed or
altered, if appropriate;
(12)
anesthesia records including pre-operative diagnosis and post-anesthesia
follow-up;
(13) a pathology report,
if tissue or body fluid is removed;
(14) recovery room records;
(15) labor record;
(16) delivery record;
(17) record of a neonatal physical
examination and condition on discharge;
(18) if the patient was in inpatient care for
48 hours or more, a discharge summary, prepared and signed by the attending
physician or mid-level practitioner, that summarizes
(A) significant findings and events of the
patient's stay in the facility;
(B)
conclusions as to the patient's primary and any associated diagnoses;
and
(C) disposition of the patient
at discharge including instructions, medications, and recommendations and
arrangements for future care; and
(19) if the patient was in inpatient care for
less than 48 hours, a final discharge progress note signed by the attending
physician or mid-level practitioner.
(d) A facility must maintain procedures to
protect the information in medical records from loss, defacement, tampering, or
access by unauthorized persons. A patient's written consent is required for
release of information that is not authorized to be released without consent. A
facility may not use or disclose protected health information except as
required or permitted by 45 C.F.R. Part 160, subpart C, and 45 C.F.R. Part 164, subpart E, revised as of October 1, 2005, and adopted by reference.
(e) A record must be completed within 30 days
of discharge and authenticated or signed by the attending physician, dentist,
or other practitioner responsible for treatment. The facility must establish
policies and procedures to ensure timely completion of medical records. A
record may be authenticated by a signature stamp or computer key instead of the
treating practitioner's signature if the practitioner has given a signed
statement to the hospital administration that the practitioner is the only
person who
(1) has possession of the stamp or
key; and
(2) may use the stamp or
key.
(f) Medical records
must be filed in accordance with a standard health information archival system
to ensure the prompt location of a patient's medical record.
(g) The facility must ensure that a transfer
summary, signed by the physician or other practitioner responsible for
treatment, accompanies the patient, or is sent by electronic mail or facsimile
transmission to the receiving facility or unit, if the patient is transferred
to another facility or is transferred to a nursing or intermediate care service
unit within the same facility. The transfer summary must include essential
information relative to the patient's diagnosis, condition, medications,
treatments, dietary requirement, known allergies, and treatment plan.
(h) Each facility subject to the provisions
of this section, with the exception of an ambulatory surgical facility and a
frontier extended stay clinic, must employ the services of a health information
administrator who is registered by the American Health Information Management
Association or a records technician who is accredited by the American Health
Information Management Association to supervise the medical record service. If
the administrator or technician is a consultant only, the administrator or
technician must visit the facility not less than biannually to organize and
evaluate the operation of the service and to provide written reports to the
medical record service and the administration of the facility.
(i) The facility must safely preserve patient
records for at least seven years after discharge of the patient, except that
(1) x-ray films or reproductions of films
must be kept for at least five years after discharge of the patient;
and
(2) the records of minors must
be kept until the minor has reached the age of 21 years, or seven years after
discharge, whichever is longer.
(j) If a facility ceases operation, the
facility must inform the department within 48 hours before ceasing operations
of the arrangements made for safe preservation of patient records as required
in this section. The facility must have a policy for the preservation of
patients' medical records in the event of the closure of the
facility.
(k) If ownership of the
facility changes, the previous licensee and the new licensee shall, before the
change of ownership, provide the department with written documentation that
(1) the new licensee will have custody of the
patient's records upon transfer of ownership, and that the records are
available to both the new and former licensee and other authorized persons;
or
(2) arrangements have been made
for the safe preservation of patients' records, as required in this section,
and the records are available to the new and former licensees and other
authorized persons.
Notes
Verification of status as a registered health information administrator or as an accredited records technician may be obtained from the American Health Information Management Association at 233 N. Michigan Avenue, Suite 2150, Chicago, IL, 60601-5800.
Authority:AS 18.05.040
AS 18.20.085
AS 47.32.010
AS 47.32.030
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