WAC 246-320-166. Management of information

The 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.