048-25 Wyo. Code R. §§ 25-22 - Records

(a) A center shall maintain a log of all patients. The log must include, as applicable:

(i) The patient's name;

(ii) The patient's date and time of arrival;

(iii) The patient's mode of arrival;

(iv) The patient's chief complaint;

(v) Whether the patient was treated, or refused or was denied treatment;

(vi) The time of discharge or transfer;

(vii) The place that the patient discharged or transferred to, including home or hospital; and

(viii) The mode of discharge transportation.

(b) If a patient receives services at a center, the center shall create and maintain a patient medical record. A patient medical record must include, as applicable:

(i) The patient's identification and social data;

(ii) The patient's chief complaint;

(iii) The patient's triage level;

(iv) The patient's pertinent medical history;

(v) The patient's properly executed consent forms;

(vi) Reports of medical screening examinations, diagnostic and laboratory test results, and consultation findings;

(vii) All practitioners' orders and notes, nurses' notes, and reports of treatment and medications;

(viii) Any other pertinent information necessary to monitor the patient's prognosis;

(ix) The patient's final diagnosis; and

(x) The patient's discharge summary.

(c) A center shall comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the implementing regulations of HIPAA, and any other applicable law relating to the maintenance or disclosure of health information.

(d) A center shall maintain all records according to professional standards of practice, including storage of records in a secure and designated area.

(e) A center's medical records policy must:

(i) Ensure the confidentiality of patient records and safeguard against loss, destruction, or unauthorized use, in accordance with applicable law;

(ii) Govern the use and removal of records from the record storage area;

(iii) Specify the conditions under which record information may be released and to whom; and

(iv) Specify when the patient's written consent is required for release of information.

(f) Personnel records shall be maintained for each person employed at the center which include:

(i) The employment application;

(ii) Verification of criminal background check and Central Registry check;

(iii) Licensure verification;

(iv) Current certification and competency in Basic Life Support (BLS) and other certifications required under this Chapter;

(v) Immunizations and other medical tests; and

(vi) Results of medical examinations required as a part of employment.

(g) Equipment records shall be maintained per the manufacturer's recommendations.

Notes

048-25 Wyo. Code R. §§ 25-22

Adopted, Eff. 6/27/2019.