Section 11-93-21 - Medical record system(a) There shall be available sufficient, appropriately qualified staff and necessary supporting personnel to facilitate the accurate processing, checking, indexing, filing, and prompt retrieval of records and record data.(b) If the director of the medical record system is not a registered record administrator or accredited record technician, there shall be regularly scheduled visits by a qualified consultant who provides reports to the administrator at least quarterly.(c) The medical records shall clearly and accurately document a patient's identity, the diagnosis of the patient's illness, treatment, orders by medical staff, observations, and conclusion concerning the patient.(d) When a patient is transferred to another facility or discharged, there shall be a complete medical summary including current status and care, and final diagnosis.(e) There shall be a master alphabetical index of all patients admitted to the facility.(f) Patient records shall be completed on a timely basis and retained in accord with existing state laws governing retention of medical records.(g) All information contained in a patient's record, including information contained in an automated data bank, shall be considered confidential.(h) The patient's record shall be the property of the hospital whose responsibility shall be to secure the information against loss, destruction, defacement, tampering, or use by unauthorized persons.(i) There shall be written policies prepared by the hospital administration which shall govern access to, duplication of, and dissemination of information from the patient's record.(j) Written consent of the patient, if competent, or otherwise the patient's guardian, shall be required for the release of information to persons not otherwise authorized by hospital policy to receive it. Appropriate consent forms shall include: (1) Use for which requested information is to be released.(2) Specific sections or elements of information to be released.(3) Name and appropriate identification of the individual or organization desiring the information.(4) Dated signature of patient, or legal guardian, approving the release of medical record information.(k) Records shall be readily accessible and available to authorized department of health licensing personnel.(l) Histories and physicals, dictated medical reports, orders, nursing observations, discharge summaries, operative reports, and consultative reports entered in the patient's record shall be: (1) Legible, typed or written in ink;(3) Authenticated by signature and title of the individual making the entry.[Eff. 3/3/86; am and ren AUG 3, 1992] (Auth: HRS §§ 321-9, 321-11) (Imp: HRS §§ 321-9, 321-11)