La. Admin. Code tit. 48 § I-9387

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

Section I-9387 - Organization and Staffing

A. There shall be a medical records department that has administrative responsibility for maintaining medical records for every person evaluated or treated as an inpatient, outpatient or emergency patient. Medical records for patients at off-site campuses shall be integrated into the unified records system of the provider.

B. Medical records shall be under the supervision of a medical records practitioner (i.e., registered record administrator or accredited record technician) on either a full-time, part-time or consulting basis.

C. Medical records shall be legibly and accurately written in ink, dated, timed, and signed by the recording person or, if an electronic medical records system is used, authenticated, complete, properly filed and retained, and accessible.

D. If a facsimile communications system (fax) is used, the hospital shall take precautions when thermal paper is used to ensure that a legible copy is retained as long as the medical record is retained.

E. Written orders signed by a member of the medical staff shall be required for all medications and treatments administered to patients. There shall be a reliable method for personal identification of each patient. The medical staff bylaws shall include specifications for orders for the care or treatment of patients which are given to the hospital verbally or transmitted to the hospital electronically, whether by telephone, facsimile transmission or otherwise. The bylaws may grant the medical staff up to 10 calendar days following the date an order is transmitted verbally or electronically to provide the signature or countersignature for such order. Orders entered via use of computerized provider order entry (CPOE) do not require a signature if the CPOE used has an immediate download into the provider's electronic health record (EHR) as the order would be dated, timed, authenticated, and promptly placed in the medical record.

F. If rubber stamp signatures are authorized for physician use, the administrative office shall have on file a signed statement from the medical staff member whose stamp is involved that ensures that he/she is the only one who has the stamp and uses it. The delegation of their use by others is prohibited.

G. If electronic signatures are used, the hospital shall develop a procedure to assure the confidentiality of each electronic signature and to prohibit the improper or unauthorized use of any computer generated signature.

H. There shall be adequate medical record personnel to ensure prompt completion, filing and retrieval of records.

I. The hospital shall have a system of coding and indexing medical records. The system shall allow for timely retrieval by diagnosis and procedure, in order to support quality assessment and improvement evaluations.

J. The hospital shall ensure that all medical records are completed within 30 days following discharge.

K. A patient or his/her personal representative shall be given reasonable access to the information contained in his/her hospital record. The hospital shall, upon request in writing signed and dated by either the patient or personal representative initiating the request, furnish a copy of the hospital record as soon as practicable, not to exceed 15 calendar days following the receipt of the request and written authorization and upon payment of the reasonable cost of reproduction in accordance with Louisiana R.S. 40:1165.1. However, the hospital may deny the patient access if a licensed healthcare professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of the patient or another person.

L. Upon request of a competent adult victim of a sexually oriented criminal offense as defined in R.S. 15:622, or current law, the hospital that performed the forensic medical exam shall provide a reproduction of any written documentation which is in the possession of the hospital resulting from the forensic medical exam of the victim.

1. The documentation shall be provided to the victim no later than 14 days after the hospital receives the request or the hospital completes the documentation, whichever is later.

2. The reproduction of written documentation provided for in this Subsection shall be made available at no cost to the victim and may only be released at the direction of the victim who is a competent adult. This release does not invalidate the victim's reasonable expectation of privacy nor does the record become a public record after the release to the victim.

M. A hospital record may be kept in any written, photographic, microfilm, or other similar method or may be kept by any magnetic, electronic, optical or similar form of data compilation which is approved for such use by the department. No magnetic, electronic, optical or similar method shall be approved unless it provides reasonable safeguards against erasure or alteration.

N. A hospital may at its discretion, cause any hospital record or part to be microfilmed, or similarly reproduced, in order to accomplish efficient storage and preservation of hospital records.

La. Admin. Code tit. 48, § I-9387

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing LR 21:177 (February 1995), amended LR 29:2415 (November 2003), Amended by the Department of Health, Bureau of Health Services Financing, LR 491934 (11/1/2023), Amended by the Department of Health, Health Standards Section, LR 501486 (10/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S.36:254 and R.S. 40:2100-2115.