Authorship

Documentation of services shall be in accordance with The Centers of Medicare and Medicaid Services, Medicare Claims Processing Manual, Revision 4173, published November 30, 2018, incorporated herein by reference. 310:667-19-10. Signature (a) Records shall be authenticated and signed by a physician or OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 45 September 13, 2019 licensed independent practitioner. (b) Every physician or practitioner shall authenticate the entries which he or she makes except as allowed at OAC 310:667-19-2(c)(4) and OAC 310:667-19-10(e). (c) A single signature on the face sheet of the record shall not suffice to authenticate the entire record. (d) Rubber stamp signatures may be used in any place in the medical record that requires a signature, provided signature identification can be verified. Authentication of reports by physicians or practitioners shall not take place prior to review of the final report by the physician or practitioner. Facilities allowing physicians and practitioners to use signature stamps to authenticate entries in the medical record shall have on file a signed statement from each such physician or practitioner that they have jurisdiction over the stamp. The use of signature stamps shall be approved in writing by the hospital administrator and medical records committee (or equivalent). (e) Reports of history and physical examinations and discharge summaries may be authenticated by an authorized physician or practitioner other than the physician or practitioner who performed the examination or produced the summary when this practice is defined and approved in the medical staff bylaws or rules and regulations. If allowed, medical staff bylaws or rules and regulations must identify the physicians or practitioners who may authenticate another physician’s or practitioner’s report of history and physical examination or discharge summary, e.g. physician partners or attending physicians or practitioners, and define the circumstances under which this practice is allowed. The bylaws or rules and regulations must also specify that when a covering or attending physician or practitioner authenticates another physician’s or practitioner’s report of history and physical examination or discharge summary, such an authentication indicates that the covering or attending physician or practitioner assumes responsibility for his or her colleague’s report or summary and verifies the document is complete, accurate, and final. (f) Electronic or computerized signatures may be used any place in the medical record that requires a signature, provided signature identification can be verified. Computerized authorization shall be limited to a unique identifier (confidential code) used only by the individual making the entry. Authentication of reports by physicians or practitioners shall not take place prior to review of the final report by the physician or practitioner. Electronic or computerized signature shall be the full, legal name of physician or practitioner and include the professional title. The use of computerized or electronic signatures shall be approved in writing by the hospital administrator and medical records committee (or equivalent). Each physician or practitioner using an electronic or computerized signature shall sign and file a statement in the hospital administrator's office which states that: (1) The physician or practitioner shall use an electronic or computer generated signature to authenticate his entries in the medical record; (2) The signature shall be generated by a confidential code which only the physician or practitioner possesses; (3) No person other that the physician or practitioner shall be permitted to use the signature. OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 46 September 13, 2019 [Source: Added at 12 Ok Reg 1560, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok Reg 1664, eff 6-12-2003; Amended at 21 Ok Reg 2785, eff 7-12-2004] 310:667-19-11. Emergency medical records (a) Complete medical records shall be kept on every patient seen and/or treated in the emergency room and shall contain as a minimum the following: (1) Patient identification. (2) Time and means of arrival. (3) History of disease or injury. (4) Physical findings. (5) Laboratory and x-ray reports, if any. (6) Diagnosis and therapeutic orders. (7) Record of treatment, including vital signs. (8) Disposition of the case. (9) Signature of the registered nurse. (10) Signature of the licensed independent practitioner, if applicable. (11) Signature of the physician, if applicable. (12) Documentation if patient left against medical advice. (b) Medical records for patients seen and/or treated in the emergency room shall be organized and filed by the medical records department. (c) Where appropriate, medical records of emergency services shall be integrated with those of the inpatient and outpatient services. (d) Emergency medical records shall be kept, as a minimum, as required by state and federal statutes. [Source: Added at 12 Ok Reg 1560, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok Reg 1664, eff 6-12-2003] 310:667-19-12. Outpatient medical records (a) Outpatient medical records shall be maintained and correlated with other hospital medical records. (b) The outpatient medical record shall be filed in a location which ensures accessibility to the physicians and licensed independent practitioners, nurses, and other personnel of the department. (c) The outpatient medical record shall be integrated with the patient's overall hospital record. (d) Information contained in the medical record shall be complete and sufficiently detailed relative to the patient's history, physical examination, laboratory and other diagnostic tests, diagnosis, and treatment to facilitate continuity of care. [Source: Added at 12 Ok Reg 1560, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok Reg 1664, eff 6-12-2003] 310:667-19-13. Promptness of record completion (a) Current records and those on discharged patients shall be completed promptly. (b) All dictated reports shall include the date of dictation and the date of transcription. OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 47 September 13, 2019 (c) Medical record transcription shall be timely. Current records; e.g. progress notes, consultation reports, operative notes, radiology reports, shall be transcribed and available for review in the medical record within forty-eight (48) hours of dictation. (d) History and physical examinations shall be completed, signed, and placed in the medical record within forty-eight (48) hours following admission or not more than thirty (30) days prior to admission. (e) When the medical history and physical examination are completed within thirty (30) days before admission, the hospital must ensure that an updated medical record entry documenting an examination for any changes in the patient's condition is completed. A timely review of the prior history and physical examination or an updated examination must be completed and documented in the patient's medical record within forty- eight (48) hours. (f) Records of patients discharged shall be completed within thirty (30) days following discharge. (g) If a patient is readmitted within thirty (30) days for the same condition, reference to the previous history and physical examination with an interval note shall suffice. [Source: Added at 12 Ok Reg 1560, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok Reg 1664, eff 6-12-2003; Amended at 24 Ok Reg 1189, eff 4-2-2007(emergency); Amended at 25 Ok Reg 2472, eff 7-11-2008] 310:667-19-14. Retention and preservation of records (a) State retention requirements. Medical records shall be retained a minimum of five (5) years beyond the date the patient was last seen or a minimum of three (3) years beyond the date of the patient's death. Records of newborns or minors shall be retained three (3) years past the age of majority. (b) Preservation of records. (1) Hospitals may microfilm, put on optical disk, or adopt similar recording technology to record the medical records and destroy the original record in order to conserve space. (2) Records reconstituted from the technology employed to conserve space shall be considered the same as the original and the retention of the technically retained record constitutes compliance with preservation laws. (3) The minimum contents of a medical record to be recorded shall be as required by OAC 310:667-19-8. (4) In the event of closure of a hospital, the hospital shall inform the Department of the disposition of the records. Disposition shall be in a manner to protect the integrity of the information contained in the medical record. These records shall be retained and disposed of in a manner consistent with the statute of limitations. [Source: Added at 12 Ok Reg 1560, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok Reg 1664, eff 6-12-2003] SUBCHAPTER 21. DRUG DISTRIBUTION OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 48 September 13, 2019