Ch. 14, § 14. Medical Records

(a) The facility shall maintain a medical records system in accordance with writ- ten policies and procedures: (i) The facility shall employ adequate personnel to ensure professional standards of practice for medical records are met. (ii) The facility shall create and maintain a record for each person receiv- ing health care services from the facility that includes, if applicable: (A) Identification and social data; (B) Admitting diagnosis; (C) Pertinent medical history; (D) Properly executed consent forms; (E) Reports of physical examinations, diagnostic and laboratory test results, and consultation findings; (F) All physician’s orders, nurse’s notes, and reports of treatments and medications; (G) Final diagnosis; (H) Discharge summary; and (I) Any other pertinent information necessary to monitor the patient’s prognosis. (iii) Each record shall include the signatures of the physician and the health care professionals documentation. (iv) Records of a discharged patient shall be completed within fifteen (15) days of the discharge date. (v) The facility shall have written policies and procedures ensuring the confidentiality of patient records, safeguards against loss, destruction, or unauthorized use, in accordance with applicable state and federal law and including policies and proce- dures which: (A) Govern the use and removal of records from the record storage area; (B) Specify the conditions under which record information may be released and to whom; (C) Specify when the patient’s written consent is required for re- lease of information.