Idaho Admin. Code r. 16.03.14.360 - MEDICAL RECORDS SERVICE
The
01.
Facilities. The hospital shall provide a medical record room, equipment,
and facilities for the retention of medical records. Provision shall be made
for the safe storage of medical records. (3-17-22)
02.
Policies and Procedures.
There shall be written policies and procedures for the operation of the medical
records service. (3-17-22)
03.
Maintenance of Records. A medical record shall be maintained for
every person who is evaluated or treated as an inpatient, outpatient, emergency
patient or a home care patient . (3-17-22)
04.
Access to Records. Only
authorized personnel shall have access to the record. (3-17-22)
05.
Release of Medical
Information. No release of medical information shall be made without
written consent of the patient or by official court order except to legally
authorized entities such as third party payors, peer review organizations,
licensing agency, etc. (3-17-22)
06.
Removal of Medical Records.
Medical records shall only be removed from the hospital in accordance with
written hospital procedures. (3-17-22)
07.
Retention. Records shall be
retained to conform with Section
39-1394, Idaho Code.
(3-17-22)
08.
Personnel. The medical records service shall be under the overall
direction of a Registered Health Information Administrator or a Registered
Health Information Technician. If the person in charge of records is not so
trained, the facility shall retain an R.H. I.A. or R.H.I.T. on a regular
consulting basis. (3-17-22)
09.
Identification and Filing. A system of identifying and filing to
ensure prompt retrieval of patient 's records shall be maintained as follows:
(3-17-22)
a. Any system shall bear at least
the name, address, birthdate, medical record number, dates of admission and
discharge; and (3-17-22)
b. Each
record shall be maintained so that both in and outpatient records for treatment
are readily retrievable. (3-17-22)
10.
Centralizing and Completion of
Records and Reports. All (clinical) information pertinent to the
patient 's stay shall be centralized in the record as follows: (3-17-22)
a. All reports shall be filed with the
record. Copies of reports are acceptable; and (3-17-22)
b. All reports and records shall be completed
and filed within thirty (30) days following discharge.
(3-17-22)
11.
Indexing of Records. Records shall be indexed as follows:
(3-17-22)
a. According to disease, operation,
and physician ; and (3-17-22)
b. Any
recognized system can be used. As additional indices become appropriate (due to
medical advance), their use shall be adopted; and (3-17-22)
c. The card index or other record for disease
or operation shall list all essential data; and (3-17-22)
d. Records of diagnoses and operations shall
be expressed in terminology that describes the morbid condition by site,
etiology, or method of procedure; and (3-17-22)
e. Indexing shall be current within six (6)
months following discharge of the patient . (3-17-22)
12.
Record Content. The medical
records shall contain sufficient information to justify the diagnosis, warrant
the treatment and end results. The medical record shall also be legible, shall
be written with ink or typed, and shall contain the following information:
(3-17-22)
a. Admission date; and
(3-17-22)
b. Identification data
and consent forms; and (3-17-22)
c.
History, including chief complaint, present illness, inventory of systems, past
history, family history, social history and record of results of physical
examination and provisional diagnosis that was completed no more than seven (7)
days before or within forty-eight (48) hours after admission; and
(3-17-22)
d. Diagnostic,
therapeutic and standing orders; and (3-17-22)
e. Records of observations, that shall
include the following: (3-17-22)
i.
Consultation written and signed by consultant that includes his findings; and
(3-17-22)
ii. Progress notes
written by the attending physician ; and (3-17-22)
iii. Progress notes written by the nursing
personnel; and (3-17-22)
iv.
Progress notes written by allied health personnel.
(3-17-22)
f. Reports of
special examinations including but not limited to: (3-17-22)
i. Clinical and pathological laboratory
findings; and (3-17-22)
ii. X-ray
interpretations; and (3-17-22)
iii.
E.K.G. interpretations. (3-17-22)
g. Conclusions that include the following:
(3-17-22)
i. Final diagnosis; and
(3-17-22)
ii. Condition on
discharge; and (3-17-22)
iii.
Clinical resume and discharge summary; and (3-17-22)
iv. Autopsy findings when applicable.
(3-17-22)
h. Informed
consent forms. (3-17-22)
i.
Anatomical donation request record (for those patients who are at or near the
time of death) containing: (3-17-22)
i. Name
and affiliation of requestor; and (3-17-22)
ii. Name and relationship of requestee; and
(3-17-22)
iii. Response to request;
and (3-17-22)
iv. Reason why
donation not requested, when applicable.
(3-17-22)
13.
Signature on Records. Signatures on medical records shall be noted
as follows: (3-17-22)
a. Every physician
shall sign and date the entries that that physician makes or directs to be
made. (3-17-22)
b. A single
signature on the face sheet record does not authenticate the entire record.
(3-17-22)
c. Any person writing in
a medical record shall sign his name to enable positive identification by name
and title. (3-17-22)
d. If initials
are used, an identifying signature shall appear on each page.
(3-17-22)
e. Rubber stamp
signatures can be used only by the person whose signature the stamp represents.
A signed statement to this effect shall be placed on file with the hospital
administrator. (3-17-22)
14.
Administrative Records. The
following hospital records shall be maintained: (3-17-22)
a. Daily census register; and
(3-17-22)
b. Record of admissions
and discharges; and (3-17-22)
c.
Register of live births and still births; and (3-17-22)
d. Death register; and (3-17-22)
e. Register of surgical procedures; and
(3-17-22)
f. Register of
outpatients; and (3-17-22)
g.
Emergency room admissions; and (3-17-22)
h. Narcotic and barbiturate record; and
(3-17-22)
i. Annual report. Each
year the hospital shall file with the licensing agency an Application for
License and Annual Report form furnished by the agency; and (3-17-22)
j. Vital statistics. Hospitals licensed under
these rules shall comply with the provisions of Idaho Department of Health and
Welfare Rules, IDAPA 16.02.08, "Vital Statistics Rules."
(3-17-22)
15.
Availability of Records. The entire medical record of any person
who is a patient , or who has been a patient in any hospital in Idaho, shall be
available to the state licensing agency or authorized representatives of the
agency, during the survey process or a complaint investigation.
(3-17-22)
16.
Standing
Orders. There shall be an annual review and approval of standing orders,
and a current signed and dated copy of approved orders shall be available. This
review shall be done by the medical staff or appropriate staff committee and
there shall be evidence of the review, signed and dated by the designated
authority. (3-17-22)
Notes
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