Medical records services

1. The general acute hospital shall establish and implement procedures to ensure that the hospital has a medical records service with administrative responsibility for medical records. a. A medical record must be maintained and kept confidential, in accordance with accepted medical record principles, for every patient admitted for care in the hospital. (1) Only authorized personnel may have access to the record. (2) Written consent of the patient must be presented as authority for release of medical information. (3) Medical records may not be removed from the hospital environment except upon subpoena or court order. (4) If a hospital discontinues operation, it shall make known to the department where its records are stored. Records are to be stored in a facility offering retrieval services for at least ten years after the closure date. Prior to destruction, public notice must be made to permit former patients or their representatives to claim their own records. Public notice must be in at least two forms, legal notice and display advertisement in a newspaper of general circulation. b. Records must be preserved in original or any other method of preservation, such as by microfilm, for a period of at least the tenth anniversary of the date on which the patient who is the subject of the record was last treated in the hospital. (1) If a patient was less than eighteen years of age at the time of last treatment, the hospital may authorize the disposal of medical records relating to the patient on or after the date of the patient's twenty-first birthday or on or after the tenth anniversary of the date on which the patient was last treated, whichever is later. (2) The hospital may not destroy medical records that relate to any matter that is involved in litigation if the hospital knows the litigation has not been finally resolved. (3) It is the governing body's responsibility to determine which records have research, legal, or medical value and to preserve such records beyond the above-identified time frames until such time in the governing body's determination the record no longer has a research, legal, or medical value. c. If a registered record administrator or accredited record technician is not in charge of medical records, a consultant registered record administrator or accredited record technician shall organize the service, coordinate the training of the personnel, and make at least quarterly visits to the hospital to evaluate the records and the operation of the service. d. Personnel must be available so that medical records services may be provided as needed. e. A system of identification and filing to ensure the prompt location of a patient's medical record must be maintained. f. Upon discharge, all clinical information pertaining to a patient's hospitalization must be centralized in the patient's medical record. The original of all reports must be filed in the medical record. g. Records must be retrievable by disease, operation, and licensed health care practitioner and must be kept up to date. For abstracting, any recognized system may be used. Indexing must be current within six months following discharge of the patient. h. The medical records must contain sufficient information to justify the diagnosis and warrant the treatment and end results. The medical records must contain the following information: identification data, chief complaint, present illness, past history, family history, physical examination, provisional diagnosis, treatment, progress notes, final diagnosis, discharge summary, nurses' notes, clinical laboratory reports, x-ray reports, consultation reports, surgical and tissue reports and applicable autopsy findings. Progress notes must be informative and descriptive of the care given and must include information and observations of significance so that they contribute to continuity of patient care. (1) The chief complaint must include a concise statement of complaints that led the patient to consult the patient's licensed health care practitioner and the date of onset and duration of each. (2) The physical examination statement must include all findings resulting from an inventory of systems. (3) The provisional diagnosis must be an impression (diagnosis) reflecting the examining licensed health care practitioner's evaluation of the patient's condition based mainly on physical findings and history. (4) Progress notes must give a chronological picture of the patient's progress and must be sufficient to delineate the course and results of treatment. The condition of the patient determines the frequency with which they are made. (5) A definitive final diagnosis must be expressed in terminology of a recognized system of disease nomenclature. (6) The discharge summary must be a recapitulation of the significant findings and events of the patient's hospitalization and the patient's condition on discharge. (7) The consultation report must be a written opinion signed by the consultant including the consultant's findings. (8) All diagnostic and treatment procedures must be recorded in the medical record. (9) Tissue reports must include a report of microscopic findings if hospital regulations require that microscopic examination be done. If only gross examination is warranted, a statement that the tissue has been received and a gross description must be made by the laboratory and filed in the medical record. (10) When an autopsy is performed, findings in a complete protocol must be filed in the record. (11) Complete records, both medical and dental, of each dental patient must be a part of the hospital record. i. All entries into the medical record must be authenticated by the individual who made the written entry. (1) All entries that the licensed health care practitioner personally makes in writing must be signed and dated by that licensed health care practitioner. (2) Telephone and verbal orders may be used provided they are given only to qualified licensed personnel and reduced to writing and dated, timed, and signed or initialed by a licensed health care practitioner responsible for the care of the patient within forty-eight hours unless the hospital policies and procedures for verbal orders and telephone orders include a process by which the reviewer of the order reads the order back to the ordering practitioner to verify its accuracy. For verbal orders and telephone orders using the read-back and verify process, the verbal orders and telephone orders must be authenticated within thirty days of discharge or within thirty days of the date the order was given if the length of stay is longer than thirty days. (3) In hospitals with medical students and unlicensed residents, the attending licensed health care practitioner shall countersign at least the history and physical examination and summary written by the medical students and unlicensed residents. (4) Signature stamps may be utilized consistent with hospital policies as long as the signature stamp is utilized only by the licensed health care practitioner whose signature the signature stamp represents. Written assurance must be on file from the licensed health care practitioner to indicate that the practitioner is the sole user of the signature stamp. (5) Electronic signatures may be utilized if the hospital's medical staff and governing body adopt a policy that permits authentication by electronic signature. The policy must include: (a) The categories of medical staff and other staff within the hospital who are authorized to authenticate patients' medical records using electronic signatures. (b) The safeguards to ensure confidentiality, including: [1] Each user must be assigned a unique identifier that is generated through a confidential access code. [2] The hospital shall certify in writing that each identifier is kept strictly confidential. This certification must include a commitment to terminate the user's use of that particular identifier if it is found that the identifier has been misused. Misused means that the user has allowed another individual to use the user's personally assigned identifier, or that the identifier has otherwise been inappropriately used. [3] The user must certify in writing that the user is the only individual with user access to the identifier and the only individual authorized to use the signature code. [4] The hospital shall monitor the use of the identifiers periodically and take corrective action as needed. The process by which the hospital will conduct the monitoring must be described in the policy. (c) A process to verify the accuracy of the content of the authenticated entries, including: [1] A system that requires completion of certain designated fields for each type of document before the document may be authenticated, with no blanks, gaps, or obvious contradictory statements appearing within those designated fields. The system must require that correction or supplementation of previously authenticated entries must be made by additional entries, separately authenticated and made subsequent in time to the original entry. [2] The system must make an opportunity available to the user to verify that the document is accurate and that the signature has been properly recorded. [3] As a part of the quality improvement activities, the hospital shall periodically sample records generated by the system to verify the accuracy and integrity of the system. (d) A user may terminate authorization for use of an electronic signature upon written notice to the staff member in charge of medical records or other individual designated by the hospital's policy. (e) Each report generated by the user must be separately authenticated. (f) A list of these codes must be maintained under adequate safeguards by hospital administration. j. Current records and those on discharged patients must be completed promptly. (1) Past history and physical examination information must be completed within twenty-four hours following admission. (2) All reports or records must be completed and filed within a period consistent with current medical practice and not longer than thirty days following discharge. (3) If a patient is readmitted within a month's time for the same conditions, reference to the previous history with an interval note and physical examination suffices. 2. Primary care hospitals are subject to the medical records services requirements for general acute hospitals in this section. 3. Specialized hospitals are subject to the medical records services requirements for general acute hospitals in this section.