Section 246-320-166 - Management of informationThe purpose of this section is to improve patient outcomes and hospital performance through obtaining, managing, and using information.
Hospitals must:
(1) Provide medical staff, employees and other authorized persons with access to patient information systems, resources, and services;(2) Maintain confidentiality, security, and integrity of information;(3) Initiate and maintain a medical record for every patient assessed or treated including a process to review records for completeness, accuracy, and timeliness;(4) Create medical records that: (a) Identify the patient;(b) Have clinical data to support the diagnosis, course and results of treatment for the patient;(c) Have signed consent documents;(d) Promote continuity of care;(e) Have accurately written, signed, dated, and timed entries;(f) Indicate authentication after the record is transcribed;(g) Are promptly filed, accessible, and retained according to RCW 70.41.190 and chapter 5.46 RCW; and(h) Include verbal orders that are accepted and transcribed by qualified personnel;(5) Establish a systematic method for identifying each medical record, identification of service area, filing, and retrieval of all patient's records; and(6) Adopt and implement policies and procedures that address:(a) Who has access to and release of confidential medical records according to chapter 70.02 RCW;(b) Retention and preservation of medical records according to RCW 70.41.190;(c) Transmittal of medical data to ensure continuity of care; and(d) Exclusion of clinical evidence from the medical record.Wash. Admin. Code § 246-320-166
Statutory Authority: Chapter 70.41 RCW and RCW 43.70.040. 09-07-050, § 246-320-166, filed 3/11/09, effective 4/11/09.