6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 10

Current through Register Vol. 47, No. 20, October 25, 2024

Part 10 - HEALTH INFORMATION MANAGEMENT

10.1 Each hospital shall comply with the requirements of 6 CCR 1011-1, Chapter 2, Part 6, regarding patient access to medical records.

10.2 A complete and accurate medical record shall be maintained on each inpatient and outpatient evaluated or treated in any part or location of the hospital from the time of initiation of services through discharge.

10.3 A registered record administrator or other trained medical record practitioner shall be responsible for the administration and functions of the health information management service.

10.4 There shall be a sufficient number of regular full-time and part-time employees so that health information management services may be provided as needed.

10.5 Medical records shall be stored in a manner to:

(A) Provide protection from loss, damage, and unauthorized use;

(B) Preserve the confidentiality of health information; and

(C) Allow for the prompt retrieval of records.

10.6 Medical records shall be preserved as original records, in a manner determined by the hospital:

(A) For minors, for the period of minority plus ten (10) years (i.e., until the patient is age 28) or ten (10) years after the most recent patient usage, whichever is later.

(B) For adults, for ten (10) years after the most recent patient care usage of the medical record.

10.7 After the required time of record preservation, records may be destroyed at the discretion of the hospital in accordance with the hospital's record retention policy. Hospitals shall establish procedures for notification to patients whose records are to be destroyed prior to the destruction of such records.

10.8 If a hospital ceases operation, the hospital shall make provision for the secure, safe storage, and prompt retrieval of all medical records for the period specified in Part 10.6 above.

(A) A hospital that ceases operation shall comply with the provisions of 6 CCR 1011-1, Chapter 2, Part 2.14.4.

10.9 All orders for diagnostic procedures, treatments, and medications shall be signed by the physician or other licensed independent practitioner and entered into the medical record. The prompt completion of a medical record shall be the responsibility of the attending physician or other licensed independent practitioner. Authentication may be by written signature, identifiable initials, or computer key.

10.10 The medical record shall contain information necessary to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services.

10.11 All medical records shall include, at a minimum, the following:

(A) Admitting diagnosis, history, and physical examination completed no more than thirty (30) days prior to admission of the patient or within twenty-four (24) hours after the patient's admission to the hospital. If the examination was completed prior to admission, an admission status examination of the patient shall be completed and documented in the medical record within twenty-four (24) hours after admission.

(B) Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient.

(C) Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and/or anesthesia.

(D) Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by federal or state law, if applicable, to require written patient consent.

(E) All practitioners' orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, vital signs, and other information necessary to monitor the patient's condition.

(F) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care.

(G) Final diagnosis with completion of medical records within (thirty) 30 days following discharge.

10.12 The following hospital records shall be maintained:

(A) Daily census,

(B) Admissions and discharge report,

(C) Chronological register of all deliveries including live and stillbirths,