410 Ind. Admin. Code 26-7-1

Current through December 12, 2024

Section 410 IAC 26-7-1 - Medical records, storage, and administration

Authority: IC 16-21-1-7; IC 16-21-2-2.5

Affected: IC 16-21-1; IC 16-21-2

Sec. 1.

(a) The abortion clinic must do the following:

(1) Create and maintain a medical record on each surgical abortion patient.

(2) Have a written policy that ensures responsibility for and maintenance of surgical abortion records as follows:

(A) The clinic must establish and implement the following:

(i) Policies and procedures to assure that the care and services provided to each patient are appropriately documented.

(ii) A system to assure that medical records are readily available in accordance with clinic policy and systematically organized to facilitate the compilation and retrieval of information.

(B) The policy must provide safeguards to assure protection of the medical records from the following:

(i) Fire.

(ii) Water.

(iii) Other sources of damage.

(C) All original medical records or legally reproduced medical records must be maintained by the clinic for a period of at least seven (7) years or the applicable statute of limitation, whichever is longer. Original medical records must be maintained in the clinic for at least two (2) years. Records over two (2) years old may be kept off-site but must be retrievable within forty-eight (48) business hours.

(b) A medical record must be maintained with documentation of service rendered for each surgical abortion patient of the clinic as follows:

(1) Medical records:

(A) are documented accurately and in a timely manner;

(B) are readily accessible; and

(C) permit prompt retrieval of information.

(2) A unit record system of filing should be utilized. When this is not practicable, a system must be established by the clinic to retrieve, when necessary, all divergently located record components.

(3) The clinic shall use a system of author identification and record maintenance that:

(A) ensures the integrity of the authentication; and

(B) protects the security of all record entries.

Each entry must be authenticated in accordance with the clinic and medical staff policies.

(4) Medical records must be retained in their original or legally reproduced form as required by federal or state law.

(5) Plain paper facsimile orders, reports, and documents are acceptable for inclusion in the medical record if allowed by the clinic policies.

(6) The clinic shall have a system of coding and indexing medical records that allows for timely retrieval of records in order to support continuous quality assessment and improvement activities.

(7) The clinic shall ensure the confidentiality of patient records. The clinic must develop, implement, and maintain the following:

(A) A procedure for releasing information or copies of records only to authorized individuals in accordance with federal and state laws.

(B) A procedure that ensures that unauthorized individuals cannot gain access to medical records.

(c) A written or electronic register must be kept of all patients treated that provides the following:

(1) Identification data.

(2) Treatment rendered.

(3) Attending physician.

(4) Condition on discharge.

(5) Transfers to hospital facility.

(6) Other data deemed necessary by the clinic.

410 IAC 26-7-1

Indiana State Department of Health; 410 IAC 26-7-1; filed May 11, 2006, 9:36 a.m.: 29 IR 3362; readopted filed Jul 12, 2012, 12:08 p.m.: 20120808-IR-410120196RFA

Readopted filed 9/26/2018, 2:48 p.m.: 20181024-IR-410180328RFA