6 Colo. Code Regs. § 1011-1 Chapter 13, pt. 10
Current through Register Vol. 47, No. 17, September 10, 2024
Part 10 - HEALTH INFORMATION MANAGEMENT10.1 Each FSED shall comply with the requirements of 6 CCR 1011-1, Chapter 2, Part 6, regarding patient access to medical records.10.2 The FSED shall provide sufficient space and equipment for the processing and safe storage of medical records. Records shall be maintained and stored out of direct access of water, fire, and other hazards to protect them from damage and loss. A records recovery or backup system shall be utilized to ensure that there is no loss of medical records.10.3 A person knowledgeable in health information management shall be responsible for the proper administration and protection of medical records.10.4 The FSED shall store medical records in a manner that protects patient privacy and confidentiality and allows for retrieval of records in a timely manner.10.5 Medical records shall be preserved as original records, in a manner determined by the FSED: (A) For minors, for the period of minority plus 10 years (i.e., until the patient is age 28) or 10 years after the most recent patient encounter, whichever is later.(B) For adults, ages 18 and older, for no less than seven years after the most recent patient care encounter.10.6 If an FSED ceases operation, the FSED shall make provision for secure, safe storage, and prompt retrieval of all medical records for the period specified in 10.5.10.7 An FSED that ceases operation must comply with the provisions of 6 CCR 1011-1, Chapter 2, Part 2.14.4.10.8 After the required time of record preservation, records may be destroyed at the discretion of the FSED, in accordance with the FSED's record retention policy. The FSED shall establish procedures for notification to patients whose records are to be destroyed prior to the destruction of such records.10.9 All orders for diagnostic procedures, treatments, and medications shall be authorized by the provider and entered into the medical record. The prompt completion of a medical record shall be the responsibility of the attending provider. 10.10 Authorization may be by written signature, identifiable initials, or computer key.10.11 Complete medical records shall be maintained on every patient from the time of registration for services through discharge. All entries into the record shall be dated, timed, and authorized by the appropriate personnel.10.12 All medical records shall include, at a minimum, the following, if applicable: (A) A unique medical record identification number, identification data including medical history, physical examination, and risk assessments, including psychosocial information.(B) Properly executed consent to treat forms, informed consent(s), and advance directives, when applicable.(C) Reports of physical examinations, vital signs, diagnostic and laboratory test results, reports of electromagnetic radiations (x-rays), computed tomography (CT) scans, and other radiological imaging studies, and consultative reports and findings, if any.(D) A record of patient education, medications, treatments, and procedures. Documentation shall include notation of the instructions given to patients on the date of service.(E) Documentation of complications, adverse reactions to drugs and/or anesthesia, referrals, and transfers.(F) A brief summary of the care encounter, patient disposition, and provisions for follow-up care.(G) Final diagnosis with completion of medical records within (thirty) 30 days following discharge.6 CCR 1011-1 Chapter 13, pt. 10