Section 11-99-28 - Resident 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 supervisor of medical records is not a registered records administrator, or accredited record technician, there must be qualified consultation available.(c) The following information shall be obtained and entered in the resident's record at the time of admission to the facility: (1) Identifying 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 which can be used to identify the resident without use of name when the latter is desirable.(2) Name and address of next of kin or legal guardian.(3) Sex, height, weight, and identifying marks.(4) Reason for admission or referral.(5) Language spoken or understood.(6) Information relevant to religious affiliation.(7) Admission diagnosis, summary of prior medical care, recent physical examination, tuberculosis status, and physician's orders.(8) Pre-admission evaluations completed by an interdisciplinary team not more than three months prior to admission.(d) Records during stay at the facility shall include: (1) Appropriate authorizations and consents.(2) Records of all periods of restraints with justification and authorization for each.(3) Copies of initial and periodic examinations, evaluations, and progress notes.(4) Regular review of the active treatment program in an overall plan of care setting for the goals to be accomplished through individually designed activities, therapies and treatments, and indicating which professional services or individuals are responsible for providing the care or service.(5) Entries describing treatments, medications, tests, and all ancillary services rendered.(6) Annual re-evaluations by relevant professional services.(e) When a resident is transferred to another facility or discharged, there shall be: (1) Written evidence of the reason.(2) Except in an emergency, documentation to indicate that the resident understood the reason for transfer, or that the guardian and family were notified.(3) A complete summary including current status and care, final diagnosis, and prognosis.(f) There shall be a master alphabetical index of all residents admitted to the facility.(g) All entries in the resident's record shall be: (1) Legible and typed or written in ink.(3) Authenticated by signature and title of the individual making the entry.(4) Written completely without the use of abbreviations except for those abbreviations approved by a medical consultant,(h) All information contained in a resident's record, including information contained in an automated data bank, shall be considered confidential.(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 governing access to, duplication of, and dissemination of information from the record.(k) Written consent of the resident, if competent, or the guardian shall be required for the release of information to persons not otherwise authorized to receive it. Consent forms shall include: (1) Use for which requested information is to be used.(2) Sections or elements of information to be released.(3) Consent of resident or legal guardian for release of medical record information. This consent shall include the dates during which the consent is operable.(l) Records shall be readily accessible and available to authorized department personnel.[Eff. APR 29, 1985] (Auth: HRS §§ 321-9, 321-10, 321-11, 333-53) (Imp: HRS §§ 333-53, 622-57)