Section 22-B2030. RECORD KEEPING REQUIREMENTS

 

2030.1Each hospital shall maintain records and reports in a manner to ensure accuracy and easy retrieval.

 

2030.2A medical record shall be maintained for every patient, including newborn infants, admitted for care in the hospital or treated in the emergency or outpatient service. Medical records may be created and maintained in written or electronic form, or a combination of both, provided that a complete record is accessible at all times. Medical records shall contain sufficient information to clearly identify the patient, to justify the diagnosis and treatment and to document the results accurately.

 

2030.3Each medical record shall contain, when applicable, the following information:

 

(a)Identification data;

 

(b)Chief complaint;

 

(c)Present illness;

 

(d)History and physical examination;

 

(e)Admitting diagnosis;

 

(f)All pathology/laboratory and radiology reports;

 

(g)Properly executed informed consent forms;

 

(h)Consultation reports;

 

(i)Medical practitioner orders;

 

(j)Documentation of all care and treatment, medical and surgical;

 

(k)Tissue report;

 

(l)Progress notes of all disciplines;

 

(m)Discharge summary and final diagnosis;

 

(n)Autopsy findings; and

 

(o)Advanced directives, if available.

 

2030.4Medical records shall contain entries which are dated, legible and indelibly verified. The author of each entry shall be identified and authentic. Authentication shall include signature, written initials, or computer entry.

 

2030.5Telephone or verbal orders of authorized individuals are accepted and transcribed by qualified personnel who are identified by title or category in the medical staff bylaws or rules and regulations. Telephone or verbal orders shall be authenticated as soon as is practical by the medical practitioner who is responsible for ordering, providing or evaluating the service furnished.

 

2030.6The hospital shall monitor and require medical records be completed within thirty (30) days of discharge of the patient.

 

2030.7The medical record of each patient shall be maintained and preserved, in original, microfilm, electronic or other similar form, for a period of at least ten (10) years following discharge or in the case of minors, the records shall be kept until three years after the age of majority has been attained. In cases in which a hospital ceases operation, all medical records of patients shall be transferred as directed by the patient or authorized representative to the hospital or other health care facility or health care service to which the patient is transferred. All other medical records that have not reached the required time for destruction shall be stored to assure confidentiality and the Department shall be notified of the address where stored.

 

2030.8Medical records shall be kept confidential, available only for use by authorized persons or as otherwise permitted by law. Records shall be available for examination by authorized representatives of the Department.

 

2030.9Patient information and/or records will be released only with consent of the patient or designee or as permitted by law. When a patient is transferred to another health care facility or service, appropriate information for continuity of care shall be sent to the receiving health care facility or service.

 

2030.10In addition to patient medical records, each hospital shall maintain, when applicable, the following:

 

(a)A permanent patient index that includes, but is not limited to:

 

(1)Name and identification numbers of each patient;

 

(2)Dates of admission and discharge;

 

(3)Name of admitting physician; and

 

(4)Disposition or place to which patient was discharged/transferred.

 

(b)Administrative records and reports including governing authority and departmental meeting minutes, staff orientation and in-service records and staff schedules as worked for a minimum of three years, unless longer is required by law.

 

(c)Records of all reports made regarding abuse, neglect, misappropriation of property or exploitation.

 

2030.11In order to ensure the patient's right of confidentiality, medical records are destroyed or disposed of by shredding, incineration, electronic deletion, or another equally effective protective measure.

 

source

Notice of Final Rulemaking published at 55 DCR 8813 (August 15, 2008).