410 Ind. Admin. Code 27-7-1

Current through November 6, 2024

Section 410 IAC 27-7-1 - Medical records; storage; administration

Authority: IC 16-21-1-7; IC 16-21-2-2.5

Affected: IC 16-21-1

Sec. 1.

(a) The birthing center must do the following:

(1) Create and maintain a medical record on each patient.

(2) Have a written policy that ensures responsibility for and maintenance of medical records as follows:

(A) The center must establish and implement the following:

(i) Policies and procedures to assure that the care and services provided to each patient are appropriately documented.

(ii) A system to assure that medical records are readily available in accordance with center policy and systematically organized to facilitate the compilation and retrieval of information.

(B) The policy must provide safeguards to assure protection of the medical records from the following:

(i) Fire.

(ii) Water.

(iii) Other sources of damage.

(C) All original medical records or legally reproduced medical records must be maintained by the center for a period of at least seven (7) years or the applicable statute of limitation, whichever is longer. Original medical records must be maintained in the center for at least two (2) years. Records over two (2) years old may be kept off-site but must be retrievable within forty-eight (48) business hours.

(b) A medical record must be maintained with documentation of service rendered for each patient of the center as follows:

(1) Medical records:

(A) are documented accurately and in a timely manner;

(B) are readily accessible; and

(C) permit prompt retrieval of information.

(2) A unit record system of filing should be utilized. When this is not practicable, a system must be established by the center to retrieve, when necessary, all divergently located record components.

(3) The center shall use a system of author identification and record maintenance that:

(A) ensures the integrity of the authentication; and

(B) protects the security of all record entries.

Each entry must be authenticated in accordance with the center and medical staff policies.

(4) Medical records must be retained in their original or legally reproduced form as required by federal or state law.

(5) Plain paper facsimile orders, reports, and documents are acceptable for inclusion in the medical record if allowed by the center policies.

(6) The center shall have a system of coding and indexing medical records that allows for timely retrieval of records by:

(A) identification data;

(B) diagnosis;

(C) treatment rendered;

(D) physician;

(E) condition on discharge; and

(F) transfer to hospital;

in order to support continuous quality assessment and improvement activities.

(7) The center shall ensure the confidentiality of patient records. The center must develop, implement, and maintain the following:

(A) A procedure for releasing information or copies of records only to authorized individuals in accordance with federal and state laws.

(B) A procedure that ensures that unauthorized individuals cannot gain access to medical records.

(c) A written or electronic register must be kept of all patients treated that provides the following:

(1) Identification data.

(2) Treatment rendered.

(3) Attending or primary physician.

(4) Medical staff person performing the delivery.

(5) Condition on discharge.

(6) Transfers to hospital facility.

(7) Other data deemed necessary by the center.

410 IAC 27-7-1

Indiana State Department of Health; 410 IAC 27-7-1; filed Feb 3, 2006, 2:00 p.m.: 29 IR 1912; readopted filed Jul 12, 2012, 12:09 p.m.: 20120808-IR-410120265RFA

Readopted filed 9/26/2018, 2:48 p.m.: 20181024-IR-410180328RFA