6 Colo. Code Regs. § 1011-1-22-7
Current through Register Vol. 47, No. 22, November 25, 2024
Section 6 CCR 1011-1-22-7 - HEALTH INFORMATION MANAGEMENT7.1 The facility shall provide sufficient space and equipment for the processing and the safe storage of health information 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 health information records.7.2 A person knowledgeable in health information management shall be responsible for the proper administration and protection of health information.7.3 The facility shall store health information in a manner that protects client privacy and confidentiality and allows for retrieval of records in a timely manner.7.4 Retention (A) With the exception of health information records of minors (individuals under the age of 18 years) records shall be preserved as original records, on microfilm, or electronic format for no less than seven years after the most recent client care encounter, after which time records may be destroyed at the discretion of the facility.(B) Health information records of minors shall be preserved for the period of minority plus 10 years.7.5 General Content (A) Complete health information records shall be maintained on every client from the time of registration for services through discharge. All entries into the record shall be dated, timed, and signed by the appropriate personnel.(B) All orders for diagnostic procedures, treatments and medications shall be signed by the clinical staff or other authorized licensed practitioners submitting them and entered in the record in ink or type, as a facsimile, or by electronic means. The prompt completion of the health information record shall be the responsibility of the clinical staff. Authentication may be by written signature, identifiable initials or computer key.(C) The record shall contain accurate documentation of significant clinical information pertaining to the client and newborn sufficiently detailed and organized in such a manner to enable:(1) another practitioner to assume care of the client or newborn at any time.(2) evaluation of the quality of client care by the quality management program.(3) the clinical staff to utilize the record to instruct the client and family members.(4) the clinical staff to determine high risk factors throughout the pregnancy, labor, delivery and postpartum period.7.6 Content of Adult Client Record(A) The records of adult clients shall contain, but not be limited to: (1) identification data including history, physical examination, and risk assessments, including psychosocial information. Each client shall have a unique medical record identification number.(2) executed informed consent(s) which shall be obtained prior to the onset of labor.(3) all laboratory testing results, including but not limited to, test results for rubella screening and RH factor.(4) clinical observations, interventions, and medications administered during prenatal care, labor and delivery, and immediate postpartum care.(5) medical orders and, if applicable, consultative reports.(6) complications, referrals, and transfers.(9) the family member or support person designated by the client, who will care for the newborn in the event that the adult client is separated from the newborn.7.7 Content of Newborn Record (A) Records of newborns shall be maintained as separate records. The clinical records of the newborn shall contain: (1) date and time of birth, birth weight and length, period of gestation, sex and condition of infant on delivery (including Apgar and any resuscitative measures taken).(2) record of ophthalmic prophylaxis.(3) record of administration of Rh immune globulin, if any.(4) physical examination at birth and at discharge.(5) genetic screening, PKU or other metabolic disorders report.(6) fetal monitoring record.(7) copy of birth certificate worksheet.(8) any complications, referrals and transfers.7.8 Progress Notes. The facility shall establish a standard methodology for recording client education, medications, treatments and procedures. Documentation shall include notation of the instructions given to clients at the time of discharge. All recordings shall be signed, including name and identifying title.7.9 Central Log. There shall be a log for registering births, with information about the adult client and the newborn. (A) Adult Client. The log shall contain the following information for the adult client: (5) transfer information, if applicable: (a) mode of transfer, i.e, EMS or other.(c) outcome after transfer.(B) Newborn. The log shall contain the following information for the newborn: (6) transfer information, if applicable: (a) mode of transfer, i.e, EMS or other.(c) outcome after transfer.