Idaho Admin. Code r. 16.03.14.360

Current through September 2, 2024

Section 16.03.14.360 - MEDICAL RECORDS SERVICE

The hospital shall maintain medical records that are documented accurately and timely, and that are readily accessible and retrievable.

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.

02.Policies and Procedures. There shall be written policies and procedures for the operation of the medical records service.

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.

04.Access to Records. Only authorized personnel shall have access to the record.

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.

06.Removal of Medical Records. Medical records shall only be removed from the hospital in accordance with written hospital procedures.

07.Retention. Records shall be retained to conform with Section 39-1394, Idaho Code.

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.

09.Identification and Filing. A system of identifying and filing to ensure prompt retrieval of patient's records shall be maintained as follows:

a. Any system shall bear at least the name, address, birthdate, medical record number, dates of admission and discharge; and

b. Each record shall be maintained so that both in and outpatient records for treatment are readily retrievable.

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:

a. All reports shall be filed with the record. Copies of reports are acceptable; and

b. All reports and records shall be completed and filed within thirty (30) days following discharge.

11.Indexing of Records. Records shall be indexed as follows:

a. According to disease, operation, and physician; and

b. Any recognized system can be used. As additional indices become appropriate (due to medical advance), their use shall be adopted; and

c. The card index or other record for disease or operation shall list all essential data; and

d. Records of diagnoses and operations shall be expressed in terminology that describes the morbid condition by site, etiology, or method of procedure; and

e. Indexing shall be current within six (6) months following discharge of the patient.

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:

a. Admission date; and

b. Identification data and consent forms; and

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

d. Diagnostic, therapeutic and standing orders; and

e. Records of observations, that shall include the following:

i. Consultation written and signed by consultant that includes his findings; and

ii. Progress notes written by the attending physician; and

iii. Progress notes written by the nursing personnel; and

iv. Progress notes written by allied health personnel.

f. Reports of special examinations including but not limited to:

i. Clinical and pathological laboratory findings; and

ii. X-ray interpretations; and

iii. E.K.G. interpretations.

g. Conclusions that include the following:

i. Final diagnosis; and

ii. Condition on discharge; and

iii. Clinical resume and discharge summary; and

iv. Autopsy findings when applicable.

h. Informed consent forms.

i. Anatomical donation request record (for those patients who are at or near the time of death) containing:

i. Name and affiliation of requestor; and

ii. Name and relationship of requestee; and

iii. Response to request; and

iv. Reason why donation not requested, when applicable.

13.Signature on Records. Signatures on medical records shall be noted as follows:

a. Every physician shall sign and date the entries that that physician makes or directs to be made.

b. A single signature on the face sheet record does not authenticate the entire record.

c. Any person writing in a medical record shall sign his name to enable positive identification by name and title.

d. If initials are used, an identifying signature shall appear on each page.

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.

14.Administrative Records. The following hospital records shall be maintained:

a. Daily census register; and

b. Record of admissions and discharges; and

c. Register of live births and still births; and

d. Death register; and

e. Register of surgical procedures; and

f. Register of outpatients; and

g. Emergency room admissions; and

h. Narcotic and barbiturate record; and

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

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."

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.

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.

Idaho Admin. Code r. 16.03.14.360

Effective March 17, 2022