Kan. Admin. Regs. § 28-34-144

Current through Register Vol. 43, No. 45, November 7, 2024

Section 28-34-144 - Records

(a) Each applicant and each licensee shall maintain an organized recordkeeping system that provides for identification, security, confidentiality, control, retrieval, and preservation of all staff member and volunteer records, patient medical records, and facility information.

(b) Each applicant and each licensee shall ensure that only individuals authorized by the applicant or licensee have access to patient medical records.

(c) All records shall be available at the facility for review by the secretary or the authorized agent of the secretary.

(d) For staff member and volunteer records, each applicant and each licensee shall ensure that an individual record is maintained at the facility. The record shall include all of the following information:

(1) The staff member's or volunteer's name, position, title, and the first and last date of employment or volunteer service;

(2) verification of qualifications, training, or licensure, if applicable;

(3) documentation of cardiopulmonary resuscitation certification, if applicable;

(4) if a physician, documentation of verification of competence, as required in K.A.R. 28-34-132, signed and dated by the medical director;

(5) if an individual who performs ultrasounds, documentation of ultrasound training required in K.A.R. 28-34-132 ;

(6) if a surgical assistant, documentation of training required in K.A.R. 28-34-132 ; and

(7) if a volunteer, documentation of training required in K.A.R. 28-34-132 .

(e) For patient records, each licensee shall ensure that an individual record is maintained at the facility for each patient. The record shall include all of the following information:

(1) Patient identification, including the following:

(A) Name, address, and date of birth; and

(B) name and telephone number of an individual to contact in an emergency;

(2) medical history as required in K.A.R. 28-34-137 ;

(3) the physical examination required in K.A.R. 28-34-137 ;

(4) laboratory test results required in K.A.R. 28-34-137 ;

(5) ultrasound results required in K.A.R. 28-34-137 ;

(6) the physician's estimated gestational age of the unborn child as required in K.A.R. 28-34-137 ;

(7) each consent form signed by the patient;

(8) a record of all orders issued by a physician, physician assistant, or nurse practitioner;

(9) a record of all medical, nursing, and health-related services provided to the patient;

(10) a record of all adverse drug reactions as required in K.A.R. 28-34-136 ; and

(11) documentation of the efforts to contact the patient within 24 hours of the procedure and offer and schedule a follow-up visit no more than four weeks after the procedure, as required in K.A.R. 28-34-141 .

(f) For facility records, each applicant and each licensee shall ensure that a record is maintained for the documentation of the following:

(1) All facility, equipment, and supply requirements specified in K.A.R. 28-34-133 through 28-34-136 ;

(2) ancillary services documentation required in K.A.R. 28-34-136 ;

(3) risk management activities required in K.A.R. 28-34-142 ; and

(4) submission of all reports required in K.A.R. 28-34-143 .

Kan. Admin. Regs. § 28-34-144

Authorized by L. 2011, ch. 82, sec. 9; implementing L. 2011, ch. 82, secs. 5 and 9; effective, T-28-7-11, July 1, 2011; effective Nov. 14, 2011.