048-22 Wyo. Code R. §§ 22-18 - Health Information and Management System
The health information and management system shall be maintained in accordance with accepted professional principles for every patient evaluated or treated in the rehabilitation hospital.
(a) There shall be qualified personnel
adequate to supervise, maintain, and conduct the health information and
management system function. Preferably, a Registered Health Information
Administrator (RHIA) or Medical Records/Health Information Technician (MRHIT)
will be in charge. If such a professional is not in charge, a qualified RHIA or
MRHIT on a consultant or part-time basis shall organize the function, train the
personnel, and make periodic on-site visits to evaluate the medical records
function.
(b) All medical records
and health information shall be maintained in accordance with the Health
Insurance Portability and Accountability Act (HIPAA) of 1996, 42 CFR Part 2,
and any other relevant state or federal laws relating to the maintenance of
protected health information.
(c)
Records of public rehabilitation hospitals shall be preserved, either in the
original form or by other permanent means, for a period of time determined by
the rehabilitation hospital administrator, based upon the legally approved
retention schedules for publically-funded rehabilitation hospitals established
by the Wyoming State Archives and the State Records Committee.
(d) A system of identification and filing to
ensure the prompt location of a patient's medical records shall be
maintained.
(e) Indexing shall be
current within three (3) months following discharge of the patient.
(f) Medical records shall contain sufficient
information to justify the diagnosis and warrant the treatment and end results.
(i) The medical records shall contain the
following information:
(A) Identification
data;
(B) Chief
complaint;
(C) Present
illness;
(D) Past
history;
(E) Family
history;
(F) Physical
examination;
(G) Provisional
diagnosis;
(H) Clinical laboratory
reports;
(I) X-ray
reports;
(J)
Consultations;
(K) Treatment,
medical and surgical;
(L) Tissue
report;
(M) Progress
notes;
(N) Final
diagnosis;
(O) Discharge summary;
and
(P) Autopsy findings.
(g) In rehabilitation
hospitals with house staff, the attending physician countersigns at least the
history, physical examination, and summary written by the house
staff.
Notes
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