Haw. Code R. § 11-94.2-22

Current through November, 2024

Section 11-94.2-22 - Medical record system

(a) The facility shall have available sufficient appropriately qualified staff and necessary supporting personnel to facilitate the accurate processing, auditing and analysis, indexing, filing, and prompt retrieval of records, record data, and resident health information.

(b) If the employee who supervises medical records is not a registered health information administrator or registered health information technician, there shall be regularly scheduled visits by a qualified consultant who shall provide reports to the administrator.

(c) The following information shall be obtained and entered in the resident's record at the time of admission to the facility:

(1) Personal information such as name, date, and time of admission, date and place of birth, citizenship status, marital status, social security number, or an admission number that can be used to identify the resident without use of name when the latter is desirable;

(2) Name and address of next of kin, legal guardian, surrogate, or representative holding a power of attorney;

(3) Sex, height, weight, race, and identifying marks;

(4) Reason for admission or referral;

(5) Language spoken and understood;

(6) Information relevant to religious affiliation, if any;

(7) Admission diagnosis, summary of prior medical care with listing of physicians providing care, recent physical examination, tuberculosis status, and physician's orders; and

(8) Advanced directives, as applicable.

(d) Records to be maintained and updated, as necessary, for the duration of each resident's stay shall also include:

(1) Appropriate authorizations and consents for medical procedures;

(2) Records of all periods, with physician orders, of use of physical or chemical restraints with justification and authorization for each and documentation of ongoing assessment of resident during use of restraints;

(3) Copies of initial and periodic examinations and evaluations, as well as progress notes at appropriate intervals;

(4) Regular review of an overall plan of care setting forth goals to be accomplished through individually designed activities, therapies, and treatments, and indicating which professional services or individual is responsible for providing the care or service;

(5) Entries describing all care, treatments, medications, tests, immunizations, and all ancillary services provided; and

(6) All physician's, physician assistant's, or APRN's orders completed with appropriate documentation (signature, title, and date).

(e) When a resident is transferred to another facility or discharged, there shall be:

(1) Written documentation of the reason for the transfer or discharge and efforts made by the facility to mitigate any stress that may arise due to the transfer;

(2) Documentation to indicate that the resident understood the reason for transfer, or that the duly authorized healthcare decision maker and family were notified;

(3) A complete summary including current status and care, final diagnosis, and prognosis; and

(4) Documentation of efforts made for effective discharge planning.

(f) The facility shall have available a master alphabetical index that is a permanent record of all residents admitted to the facility. The index shall include but not be limited to name, date of birth, facility medical record number, name of physician, and dates of admission and discharge.

(g) All entries in a resident's record shall be:

(1) Accurate and complete;

(2) Legible and typed or written in black or blue ink;

(3) Dated;

(4) Authenticated by signature and title of the individual making the entry; and

(5) Written completely without the use of abbreviations except for those abbreviations approved by a medical consultant or the medical doctor.

(h) All information contained in the resident's record, including any information contained in an automated data bank, shall be considered confidential and adhere to requirements as set forth by the Health Insurance Portability and Accountability Act of 1996.

(i) The record shall be the property of the facility, whose responsibility shall be to secure the information against loss, destruction, defacement, tampering, or use by unauthorized persons.

(j) There shall be written policies and procedures governing the management of resident health information including but not limited to access to, duplication of, and dissemination of information from the record, and the retention of the medical records and disposal methods as appropriate.

(k) Written consent of the resident, if competent, or the duly authorized healthcare decision maker if the resident is not competent, shall be required for the release of information to persons not otherwise authorized to receive it. Consent forms shall include:

(1) The use for which the information is requested;

(2) Sections or elements of information to be released and specific period of time during which the information is to be released; and

(3) Consent of the resident, legal guardian, or surrogate for release of any medical record information.

(l) Records shall be readily accessible and available to authorized department personnel for the purpose of determining compliance with this chapter.

(m) The facility shall retain medical records pursuant to section 622-58, HRS, in the original or reproduced form for a minimum of seven years after the last data entry, except in the case of minors, whose records shall be retained during the period of minority plus seven years after the minor reaches the age of majority.

Haw. Code R. § 11-94.2-22

[Eff 9/16/2022] (Auth: HRS §§ 321-9, 321-11) (Imp: HRS §§ 321-9, 321-11)