HAR §11-99-78
HAR §11-99-78. §11-99-78 Resident record system
Length: 535 wordsOfficial source
Cite as Haw. Code R. § 11-99-78
(a) There shall
be available sufficient, appropriately qualified staff
and necessary supporting personnel to facilitate the
accurate processing, checking, indexing, filing, and
prompt retrieval of records and record data.
(b)
If the supervisor of medical records is not a
registered records administrator, or accredited record
technician, there must be regularly scheduled visits by
a qualified consultant who shall provide reports to the
administrator.
(c)
The following information shall be obtained
and entered in the resident's record at the time of
admission to the facility.
(1)
Identifying information such as: name, date
and time of admission, date and place of
birth, citizenship status, marital status,
social security number or an admission number
which can be used to identify the resident
without use of name when the latter is
desirable.
(2)
Name and address of next of kin or legal
guardian.
(3)
Sex, height, weight, and identifying marks.
(4)
Reason for admission or referral.
(5)
Language spoken or understood.
(6)
Information relevant to religious affiliation.
(7)
Admission diagnosis, summary of prior medical
care, recent physical examination,
tuberculosis status, and physician's orders.
(8)
Preadmission evaluations completed by an
interdisciplinary team not more than three
months prior to admission.
(d)
Records during stay at the facility shall also
include:
(1)
Appropriate authorizations and consents.
(2)
Records of all periods of restraints with
justification and authorization for each.
(3)
Copies of initial and periodic examinations,
evaluations, and progress notes.
(4)
Regular review of the active treatment program
in an overall plan of care setting forth goals
to be accomplished through individually
designed activities, therapies and treatments,
and indicating which
§11-99-78
professional services or individual is
responsible for providing the care or service.
(5)
Entries describing treatments, medications,
tests, and all ancillary services rendered.
(6)
Annual re-evaluations by all professional
services including at least a physician,
dentist, psychologist, social worker, and
nurse.
(e)
When a resident is transferred to another
facility or discharged, there shall be:
(1)
Written evidence of the reason.
(2)
Except in an emergency, documentation to
indicate that the resident understood the
reason for transfer, or that the guardian and
family were notified.
(3)
Complete summary including current status and
care, final diagnosis, and prognosis.
(f)
There shall be a master alphabetical index of
all residents admitted to the facility.
(g)
All entries in the resident's record shall be:
(1)
Legible and typed or written in ink.
(2)
Dated.
(3)
Authenticated by signature and title of the
individual making the entry.
(4)
Written completely without the use of
abbreviations except for those abbreviations
approved by a medical consultant or the
medical director.
(h)
All information contained in a resident's
record, including information contained in an automated
data bank, shall be considered confidential.
(i)
The record shall be the property of the
facility, whose responsibility shall be to secure the
information against loss, destruction, defacement,
tampering, or use by unauthorized persons.
(j)
There shall be written policies governing
access to, duplication of, and dissemination of
information from the record.
(k)
Written consent of the resident, if competent,
or the guardian shall be required for the release of
information to persons not otherwise authorized to
receive it. Consent forms shall include:
(1)
Use for which requested information is to be