Section 410 IAC 15-2.5-3 - Medical records, storage, and administrationAuthority: IC 16-21-1-7
Affected: IC 16-21-1
Sec. 3.
(a) The medical record service has administrative responsibility for the medical records that must be maintained for every patient of the center.(b) The organization of the medical record service must be appropriate to the scope and complexity of the services provided as follows:(1) The services must be directed by a registered record administrator (RRA) or an accredited record technician (ART). If a full-time and/or part-time RRA or ART is not employed, then a consultant RRA or ART must be provided to assist the qualified person in charge. Documentation of the findings and recommendations of the consultant must be maintained.(2) The medical record service must be provided with necessary direction, staffing, and facilities to perform all required functions in order to ensure prompt completion, filing, and retrieval of records.(c) An adequate medical record must be maintained with documentation of service rendered for each patient of the center as follows:(1) Medical records are documented accurately and in a timely manner, are readily accessible, and 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 ensures the integrity of the authentication and 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 which allows for timely retrieval of records by diagnosis and procedure, physician, and condition on discharge, 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 patient records.(d) The medical record must contain sufficient information to: (1) identify the patient;(2) support the diagnosis;(3) justify the treatment; and(4) document accurately the course of the patient's stay in the center and the results.(e) All entries in the medical record must be as follows:(1) Legible and complete.(2) Made only by authorized individuals as specified in center and medical staff policies.(3) Authenticated and dated in accordance with section 4(b)(3)(N) of this rule.(f) All patient records must document and contain, at a minimum, the following:(1) Patient identification.(2) Appropriate medical history and results of a physical examination completed within the time frames in section 4(b)(3)(M) of this rule.(3) Preoperative diagnostic studies recorded in the record before surgery, if performed.(4) Any allergies and abnormal drug reactions.(5) Entries related to anesthesia administration.(6) Evidence of appropriate informed consent for procedures and treatments for which it is required as specified by the informed consent policy developed by the medical staff and governing board, and consistent with federal and state law.(8) Medical history, chief complaint, and physical examination, including copies of laboratory, x-ray consultations, and other special reports or summary of those same findings by the admitting physician.(9) A written or dictated report describing techniques, findings, and tissue removed or altered.(10) Signatures of physicians and health care workers who treated or cared for the patient.(11) Condition on discharge, disposition of the patient, and time of dismissal.(12) Final progress note, including instructions to the patient and family, with dismissal diagnosis.(13) A copy of the transfer form, if the patient is referred to a hospital or other facility.(g) All original medical records or legally reproduced medical records must be maintained by the center for a period of seven (7) years in accordance with subsection (c)(6) and (c)(7), must be readily accessible, in accordance with the center policy, and must be kept in a fire resistive structure.Indiana State Department of Health; 410 IAC 15-2.5-3; filed Dec 1, 1999, 3:44 p.m.: 23 IR 788; errata filed Feb 15, 2000, 8:05 a.m.: 23 IR 1657; readopted filed Jul 15, 2005, 8:00 a.m.: 28 IR 3661; readopted filed Jul 14, 2011, 11:42 a.m.: 20110810-IR-410110253RFAReadopted filed 9/13/2017, 4:08 p.m.: 20171011-IR-410170339RFAReadopted filed 11/28/2023, 12:13 p.m.: 20231227-IR-410230639RFA