Hospital Patient Records

In addition to meeting rule 0940-05-06-.05 Individual Client Records, the governing body must ensure that the following requirements are met: (1) A person must be designated to be responsible for supervision of medical records. This person must be a qualified medical records practitioner or receive consultation from a qualified individual. (2) An individual, separate and complete medical record must be maintained for each patient which includes: (a) Documentation of any referrals made by the facility and the results of these referrals; (b) List of the patient’s personal property valued at fifty dollars ($50.00) or more including its disposition, if no longer in use; (c) Written accounts of all monies received and disbursed on behalf of the patient; (d) Reports of abuse, accidents, seizures, illnesses, treatments for such abuse accidents, seizures and illnesses, immunizations and significant behavior incidents; (e) Documentation of any instance of seclusion, restraint, or restriction with justification and authorization; (f) Appropriate consents and authorizations for the release or obtaining of information about the patient including a standardized release of information which contains: 1. The name and title of the person or organization to which disclosure is to be made, 2. The name of the patient, 3. The purpose or need for the disclosure, 4. The extent and nature of information to be disclosed, 5. A statement that the consent is subject to revocation at any time except to the extent that action has already been taken in reliance thereon and a specification MINIMUM PROGRAM REQUIREMENTS FOR CHAPTER 0940-05-16 MENTAL HEALTH HOSPITAL FACILITIES of the date, event, or condition upon which the consent will expire without express revocation, 6. The date on which the consent is signed, and 7. The signature of the patient or the signature of a person authorized to sign in lieu of the patient; (g) Periodic progress notes which minimally include dates; name of the patient on each page of notes; a brief descriptive statement of the patient’s progress, or lack thereof, toward treatment plan goals; and the signature of the clinician preparing the note. Frequency of progress notes must be determined by the patient’s condition but must be at least weekly for the first month of hospitalization and monthly thereafter; (h) A discharge summary completed and authenticated to include the provisional diagnosis, primary and secondary final diagnoses, clinical resume, condition on discharge or transfer and aftercare arrangements. The discharge summary should be recorded at the time of discharge, but no later than fifteen (15) days after discharge; (i) Reason for admission including presenting problem and referral source; (j) Documentation of all medication and treatment orders including date of order, type, dosage, frequency and reason. Documentation of administration of medication must also be in the patient record; (k) Assessments, including at least the following: 1. Medical history, 2. Psychiatric history and/or chemical dependency assessment, 3. Physical examination (within twenty-four (24) hours of admission and at least annually thereafter), 4. Laboratory and other diagnostic test results when indicated, (l) Sources of financial support including social security, veterans benefits and insurance; and (m) Sources of coverage for medical care costs.