La. Admin. Code tit. 48 § I-6039

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-6039 - Records

A. There shall be a permanent record of each patient encounter made by the ambulance service. These records may be maintained as hard copy and/or electronically. The record shall be maintained to assure that the medical treatment of each patient is completely and accurately documented. Records shall be readily available and systematically organized to facilitate the compilation and copying of such information.

B. The record of each patient encounter shall include at a minimum:

1. pertinent demographic information about the patient;

2. location of the response;

3. date and time of response;

4. situation;

5. patient's chief complaint;

6. patient's signs and symptoms;

7. a synopsis of the assessment of the patient to include both the initial and complete assessment of the patient;

8. vital signs;

9. pertinent past medical history;

10. any interventions or treatments conducted;

11. transport destination and arrival time if applicable; and

12. any other significant information that pertains to the patient or to the response.

C. Safeguards shall be established and implemented to maintain confidentiality and protection of the medical record from fire, water, or other sources of damage.

D. Safeguards shall be established and implemented to maintain the confidentiality and protection of all medical records in accordance with the Health Insurance Portability and Accountability Act (HIPAA) regulations.

E. The department shall have access to all business records, patient records or other documents maintained by, or on behalf of the provider, to the extent necessary to insure compliance with this Chapter. Ensuring compliance includes, but is not limited to:

1. permitting photocopying of records by the department; and

2. providing photocopies to the department of any record or other information the department may deem necessary to determine or verify compliance with this Chapter.

F. The provider shall keep patient records for a period of six years after the patient encounter. The patient records shall:

1. remain in the custody of the provider;

2. remain in the headquarters for at least one year from the date of the last patient encounter; and

3. not be disclosed or removed unless authorized by law or regulations.

La. Admin. Code tit. 48, § I-6039

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 35:476 (March 2009).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:1235.2.