Section 79803 - Health Record Service(a) The correctional treatment center shall maintain a health record service in accordance with accepted professional standards and practices. The health record service shall have sufficient staff, facilities, and equipment, and be conveniently located to facilitate the accurate processing, checking, indexing and filing of all health records.(b) The health record service shall be under the direction of a staff member with at least two years of training and experience in records administration, at a level of responsibility equivalent to a health record technician, or a medical record technician. This designated staff member shall be assisted by such qualified personnel as are necessary to conduct the service. A registered health information administrator or registered health information technician shall provide consultation on at least a quarterly basis to designated staff members responsible for record administration.(c) If a facility, in addition to inpatient services, is providing outpatient, emergency, day treatment, or crisis intervention service, a unit health record system shall be established.(d) The facility shall have a continuing system of collecting and recording data that describe patients served in such form as to provide for continuity of care, program services, and data retrieval for program patient care evaluation and research. Health records shall be stored and systematically organized to facilitate retrieval of information. Retrievability shall be assured by the use of an acceptable coding system such as the latest version of the International Classification of Diseases (ICD-9).(e) Policies and procedures shall be established and implemented to ensure the confidentiality of access to patient health information, in accordance with federal, state and local laws and acceptable standards of practice.Cal. Code Regs. Tit. 22, § 79803
1. New section filed 6-10-94; operative 1-1-96 pursuant to Health and Safety Code section 1250 (Register 94, No. 23).
2. Change without regulatory effect amending subsection (b) and amending NOTE filed 3-12-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 11). Note: Authority cited: Sections 1275 and 131200, Health and Safety Code. Reference: Sections 1250(j), 1254, 1276, 131050, 131051 and 131052, Health and Safety Code.
1. New section filed 6-10-94; operative 1-1-96 pursuant to Health and Safety Code section 1250 (Register 94, No. 23).
2. Change without regulatory effect amending subsection (b) and amending Note filed 3-12-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 11).