La. Admin. Code tit. 48 § I-4425

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-4425 - Patient Medical Records and Reporting Requirements

A. General Provisions

1. The outpatient abortion facility shall establish and maintain a patient medical record on each patient.

2. The patient medical record shall be:

a. completely and accurately documented; and

b. readily available and systematically organized to facilitate the gathering of information.

3. The outpatient abortion facility shall ensure compliance with privacy and confidentiality of patient medical records, including information in a computerized medical record system, in accordance with the Health Insurance Portability and Accountability Act (HIPAA) regulations, and/or all applicable state laws, rules, and regulations.

4. Safeguards shall be established to protect the patient medical records from loss or damage and/or breach of confidentiality in accordance with all applicable state laws, rules, and regulations.

B. Retention of Patient Medical Records. Patient medical records shall be retained by the outpatient abortion facility for a period of not less than seven years from the date of discharge. If the woman is a minor, then the medical record of the minor shall be kept for a minimum of 10 years from the time the minor reaches the age of majority. Patient medical records shall be maintained on the premises for at least one year and shall not be removed except under court orders or subpoenas. Any patient medical record maintained off-site after the first year shall be provided to the department for review no later than 24 hours from the time of the departments request.

NOTE: Refer to R.S. 9:2800.9.

C. Contents of Patient Medical Record

1. The following minimum data shall be kept on all patients:

a. identification data;

b. date of procedure;

c. medical and social history;

d. anesthesia and surgical history;

e. physical examination notes;

f. chief complaint or diagnosis;

g. clinical laboratory reports;

h. pathology reports;

i. individualized physicians orders;

j. radiological/ultrasound reports;

k. consultation reports (when appropriate);

l. medical and surgical treatment;

m. progress notes, discharge notes, and discharge summary;

n. nurses' notes, including, but not limited to, all pertinent observations, treatments, and medications dispensed and/or administered;

o. medication administration records, including, but not limited to, the date, time, medication, dose, and route;

p. documentation of any and all prescription drugs dispensed to each patient, including, but not limited to the:

i. full name of the patient;

ii. name of the prescribing physician;

iii. name and strength of the drug;

iv. quantity dispensed; and

v. date of issue;

q. signed and dated authorizations, consents, releases, or notices required by all applicable federal, state, and local statutes, laws, ordinances, and department rules and regulations, including but not limited to:

i. a signed receipt of Point of Rescue pamphlet; and

ii. a signed certification form in accordance with applicable state law indicating acknowledged receipt of informational materials concerning psychological impacts, illegal coercion, abuse, and human trafficking;

NOTE: The provisions of this Section requiring a physician or qualified person to provide required printed materials to a woman considering an abortion shall become effective 30 days after the department publishes a notice of the availability of such materials.

r. operative report;

s. anesthesia report, including, but not limited to, the date, time, type of anesthesia, dose, and route; and

t. special procedures reports.

2. Each entry documented in the patients medical record shall be signed by the physician as appropriate, e.g., attending physician, consulting physician, anesthesiologist, pathologist, etc. Nursing notes and observations shall be signed by the licensed nurse. All entries shall be in writing and contain the date, time, and signature of the individual(s) delivering the patient care and services.

D. Nothing in this Section is intended to preclude the use of automated or centralized computer systems or any other techniques for the storing of medical records, provided the regulations stated herein are met.

E. Other Reports. The outpatient abortion facility shall maintain a daily patient roster of all patients receiving a surgical or chemically induced abortion. Patients may be identified corresponding to the patients medical record. This daily patient roster shall be retained for a period of three years.

F. Reporting Requirements

1. The outpatient abortion facility shall maintain documentation to support that the outpatient abortion facility is compliant with all reporting requirements, including, but not limited to, the induced termination of pregnancy (ITOP) form and other documentation as required by federal, state, and local statutes, laws, ordinances, and department rules and regulations.

2. The outpatient abortion facility shall report in accordance with all applicable state laws for the reporting of crimes against a child that include but are not limited to:

a. rape;

b. sexual battery;

c. incest; and

d. carnal knowledge of a juvenile.

La. Admin. Code tit. 48, § I-4425

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 41699 (4/1/2015).

AUTHORITY NOTE: Promulgated in accordance with R.S.