Section R432-500-21 - Medical Records(1) The licensee shall have written policies and procedures that ensure medical records are complete, accurately documented, and systematically organized to facilitate storage and retrieval for staff use.(2) The licensee shall ensure medical records comply with the following:(a) a permanent individual medical record is maintained for each patient admitted;(b) any entry is permanently typed or handwritten in ink, and able to be photocopied and stamps are not acceptable unless a co-signature is present;(c) each entry is authenticated with the date, name or identified initials, and title of the person making the entry;(d) records are kept current and conform to medical and professional practice based on the service provided to the patient;(e) if utilized, an automated record system meets the content requirements of this rule;(f) any records of discharged patients are completed and filed within a time frame established by written facility policy. The physician shall complete the medical record; and(g) each patient's medical record includes the following:(i) an admission record that includes the name, address, and telephone number of the patient, physician and responsible person and the patient's age and date of admission;(ii) a current physical examination and history, including allergies and abnormal drug reactions;(iii) informed consent signed by the patient or, if applicable, the patient's representative;(iv) complete findings and techniques of the operation;(v) signed and dated physician orders for medications and treatments;(vi) signed and dated nurse's notes that include vital signs, medications, treatments, and other pertinent information;(vii) discharge summary containing a brief narrative of conditions and diagnoses of the patient's final disposition, and instructions given to the patient and responsible person;(viii) the pathologist's report of human tissue removed during the surgical procedure, if any;(ix) reports of laboratory and x-ray procedures performed, consultations and any other pre-operative diagnostic studies; and(x) pre-anesthesia evaluation.(3) The licensee shall ensure medical record retention, storage and release practices comply with the following: (a) medical records are retained for at least seven years after the last date of patient care or until a minor reaches age 18 or the age of majority, plus an additional three years;(b) a new owner retains any patient records upon change of ownership;(c) provision is made for filing, safe storage, security, and easy accessibility of medical records;(d) medical record information is confidential;(e) there are written procedures for the use and removal of medical records and the release of patient information;(f) information is disclosed only to authorized persons in accordance with federal and state laws, and facility policy; and(g) requests for information identifying the patient, including photographs, require written consent by the patient.Utah Admin. Code R432-500-21
Amended by Utah State Bulletin Number 2023-17, effective 8/10/2023