6 Colo. Code Regs. § 1011-1-20-7

Current through Register Vol. 47, No. 11, June 10, 2024

Section 6 CCR 1011-1-20-7 - HEALTH INFORMATION MANAGEMENT

7.1 Facilities: The center shall develop and maintain a system for the proper collection, storage, and use of patient health information. The center shall maintain an individual record for each patient admitted.

(A) Each center shall establish processes to obtain, manage and utilize information to enhance and improve individual and organizational performance in patient care, management and support processes. Such processes shall:

(1) Be planned and designed to meet the center's internal and external information needs;

(2) Provide for confidentiality, integrity and security;

(3) Provide education and training in information management principles to decision-makers and other center personnel who generate, collect and analyze information; and

(4) Provide for information in a timely and accurate manner.

(B) The administrator shall appoint in writing a qualified person responsible for the patient information system or similarly titled unit. This person shall meet the qualifications established for this position, in writing, by the governing body.

(C) A current job description delineating duties and responsibilities shall be maintained for each medical records service position.

(D) The health information management administrator shall ensure that:

(1) Operative and procedure reports signed by the physician are recorded in the patient's health record immediately following the surgery or procedure or that a progress note is entered in the patient record to provide pertinent information;

(2) Postoperative information includes vital signs, level of consciousness, medications, blood or blood components, complications and management of those events, identification of direct providers of care, and discharge information from post-anesthesia care area; and

(3) All medical records are entered into a database and maintained on a current basis according to procedure and physician.

7.2 Security: Medical records shall be protected from loss, damage, unauthorized use and disclosure. If electronic medical records are utilized, there must be a back-up system for all data collected. An audit trail shall be maintained to track data entries and deletions, and include information regarding the data entered or deleted as well as the user responsible for the data entry or deletion.

7.3 Preservation: With the exception of medical records of minors (individuals under the age of 18 years) medical records shall be preserved as original records or on a technologically appropriate medium as administratively determined by the Department for no less than ten (10) years after the most recent patient care usage, after which time medical records may be destroyed at the discretion of the center. Accessibility of medical records to the Department to assure compliance and to patients or their legal representatives shall be maintained.

(A) Medical records of minors shall be preserved for the period of minority plus ten (10) years (i.e., 28 years less age of minor at time of most recent patient care usage of the medical record).

(B) Centers shall establish procedures for notification to patients whose records are to be destroyed prior to the destruction of such records.

(C) Centers shall be solely responsible for the destruction of all medical records.

(D) Actual x-ray films, scans, and other imaging records shall be maintained by the center for a period of five (5) years, if services are provided directly.

7.4 Content: The medical records shall contain sufficient accurate information to justify the diagnosis and warrant the treatment and end results including, but not limited to:

(A) Complete patient identification including a unique identification number;

(B) Admission and discharge dates;

(C) Chief complaint and admission diagnosis;

(D) Medical history and physical examination completed prior to surgery;

(E) Diagnostic tests, laboratory, x-ray, scans, and other radiological imaging reports and consultative findings when appropriate;

(F) Physician progress notes if appropriate;

(G) Properly executed informed consent;

(H) A pre-anesthesia examination by a physician prior to surgery, a proper anesthesia record and a post-anesthesia evaluation;

(I) A complete detailed description of operative procedures, findings and post-operative diagnosis recorded and signed by the attending physician;

(J) A pathology report of tissue removed during surgery in accordance with center policies;

(K) All medication and treatment orders in writing and signed by the authorizing party. Telephone and verbal orders are designated as such, signed and dated by a legally designated person, and countersigned by the attending provider within a clearly designated time period established by the governing body; and

(L) Patient's condition on discharge, final diagnosis, and instructions given to patient for follow-up care.

7.5 Other records: The center shall:

(A) Maintain a register of all procedures performed by practitioner (entered daily);

(B) Maintain a master patient index file; and

(C) Collect, retrieve and annually summarize the following medical statistical information:

(1) The number of patient visits,

(2) The basis of treatment (clinical diagnosis and/or problem for which the patient was treated),

(3) The types and number of procedures performed,

(4) The age distribution of patients,

(5) All complications and emergencies, and

(6) The number of times a patient was transferred from the center to a hospital.

The information shall be used to inform the governing body and as part of the center's ongoing quality management program. The beginning and ending dates for the annual summary shall be set in policy by the governing body.

(D) Nursing Records: Standard nursing practice and procedure shall be followed in the recording of medications and treatments, including operative and post-operative notes. Nursing notes shall include notation of the instructions given patients preoperatively and at the time of discharge. All nursing notes shall be entered as part of the patient's medical record. Entries shall be appropriately signed, including name and identifying title.

(E) Entries: All orders for diagnostic procedures, treatments, and medications shall be authenticated by the physician submitting them and entered in the medical record by technologically appropriate medium as administratively determined by the Department. Authentication may be by written signature, identifiable initials, computer key or other secure electronic means.

6 CCR 1011-1-20-7