N.M. Code R. § 7.7.2.30

Current through Register Vol. 35, No. 11, June 11, 2024

Section 7.7.2.30 - MEDICAL RECORDS SERVICES

A. Medical Record. A medical record shall be maintained for every patient admitted for care in the hospital. The record shall be kept confidential and released only in accordance with the Sections 14-6-1, 14-6-2 NMSA 1978 and, where appropriate, Section 43-1-19 NMSA 1978.

B. Service. The hospital shall have a medical records service with administrative responsibility for all medical records maintained by the hospital.

(1) Confidentiality:

(a) Written consent of the patient or legally authorized person shall be required for release of medical information to persons not otherwise authorized to receive this information.

(b) Original medical records may not be removed from the hospital except by authorized persons who are acting in accordance with a court order, and where measures are taken to protect the record from loss, defacement, tampering and unauthorized access.

(2) Preservation: There shall be a written policy for the preservation of medical records The retention period shall be for 10 years following the last treatment date of the patient, except in the case of minor children whose records shall be retained to the age of majority, plus one year.

(a) Laboratory test records and reports may be destroyed one year after the date of the test recorded or reported therein provided that one copy is placed in the patient's record, or stored electronically in the hospital's information system. The hospital is responsible for electronic storage.

(b) X-ray films may be destroyed four years after the date of exposure, if there are in the hospital record written findings of a radiologist who has read such x-ray films. At anytime after the third year after the date of exposure, and upon proper identification, the patient may recover his own x-ray films as may be retained pursuant to this section. The written radiological findings shall be retained as provided by these requirements.

(3) Personnel:

(a) Adequate numbers of personnel who are qualified to supervise and operate the service shall be provided.

(b) A registered medical records administrator or an accredited records technician shall head the services, except that if such a professionally qualified person is not in charge of medical records, a consultant who is a registered records administrator or an accredited records technician shall organize the service, train the medical records personnel and make at least quarterly visits to the hospital to evaluate the records and the operation of the service, and prepare written reports of findings within 30 days.

(c) In this subdivision, "a registered record administrator" or an "accredited record technician" is an individual who has successfully completed the examination requirements of the American Medical Record Association.

(4) Availability:

(a) The system for identifying and filing records shall permit prompt retrieval of each patient's medical records.

(b) A master patient index shall include at least the patient's full name, sex, birth date and medical record number and/or reference to treatment dates.

(c) Filing equipment and space shall be adequate to maintain the records and facilitate retrieval.

(d) The inpatient, ambulatory care and emergency records of patients shall be kept in such a way that all patient care information can be provided for patient care when the patient is admitted to the hospital, when the patient appears for a pre-scheduled outpatient visit, or as needed for emergency services.

(e) Pertinent medical record information obtained from other providers including patient tracking information for patients admitted during disaster and emergency shall be available to facilitate continuity of the patient's care.

(f) The original or legally reproduced form of all clinical information pertaining to a patient's stay shall be filed in the medical record folder as a unit record. When this is not feasible a system must be in place to provide prompt retrieval of all medical records when a patient is admitted.

(5) Coding and indexing:

(a) Records shall be coded and indexed according to diagnosis, operation and physician Indexing shall be kept current within six months from the discharge of the patient.

(b) Any recognized system may be used for coding diagnoses, operations and procedures.

(c) The indices shall list all diagnoses for which the patient was treated during the hospitalization and the operations and procedures, which were performed during the hospitalization.

C. Medical Record Contents. The medical record staff shall ensure that each patient's medical records contain:

(1) accurate and adequate patient identification data;

(2) a concise statement of complaints, including the chief complaint, which led the patient to seek medical care and the date of onset and duration of each;

(3) a health history, containing a description of present illness, past history of illness and pertinent family and social history to be made part of the record within the first 24 hours after admission;

(4) a statement about the results of the physical examination, including all positive and negative findings resulting from an inventory of systems;

(5) the provisional diagnosis;

(6) all diagnostic and therapeutic orders;

(7) all clinical laboratory, x-ray reports and other diagnostic reports;

(8) consultation reports containing a written opinion by the consultant that reflects, when appropriate, an actual examination of the patient and the patient's medical records;

(9) except in an emergency, a current, thorough history and physical work-up shall be recorded in the medical record of every patient prior to surgery;

(10) an operative report describing techniques and findings written or dictated immediately after surgery; the completed operative report is authenticated by the surgeon and filed in the medical record as soon as possible after surgery or available electronically in the hospital information system; when the operative report is not placed in the medical record immediately after surgery, a progress note is entered immediately;

(11) a post operative documentation record of the patient's discharge from the post anesthesia care area;

(12) tissue reports, including a report of microscopic findings if hospital policies require that microscopic examination be done; if only microscopic examination is warranted, a statement that the tissue has been received and a microscopic description of the findings shall be provided by the laboratory and filed in the medical record;

(13) progress notes providing a chronological picture of the patient's progress sufficient to delineate the course and the results of treatment;

(14) a definitive final diagnosis including all relevant treatment and operative procedures performed expressed in the terminology of a recognized system of disease nomenclature;

(15) a discharge summary including the final diagnosis, the reason for hospitalization, the significant findings, the procedures performed, the condition of the patient on discharge and any specific instructions given the patient and/or family. A final progress note is acceptable when stay is less than [48 hours and in case of normal newborn infants and uncomplicated obstetrical deliveries;

(16) autopsy findings when an autopsy is performed; and

(17) for comprehensive inpatient programs the following information shall be present as well: rehabilitation evaluation including medical, psycho-social history and physical exam; rehabilitation plans including goals for treatment; documentation of patient care conferences held minimally every two weeks, or as indicated, by appropriate disciplines involved in the care and treatment of the patient, in which the patient's treatment and response to rehabilitation services shall be evaluated and modified as indicated.

D. Authentication. Only members of the hospital staff or other professional personnel authorized by the hospital shall record and authenticate entries in the medical record. Documentation of medical staff participation in the care of the patient shall be evidenced by at least:

(1) the signature on the patient's health history as the required by medical staff by-laws and results of his or her physical examination;

(2) periodic progress notes or countersignatures as defined by the hospital rules and regulations;

(3) the surgeon's signature on the operative report; and

(4) the signature as required by medical staff by-laws on the face sheet and discharge summary.

E. Completion.

(1) Current records and those on discharged patients shall be completed promptly.

(2) If a patient is readmitted within 30 days for the same or related condition, there shall be a reference to the previous history with an interval note, and any pertinent changes in physical findings shall be recorded.

(3) All records of discharged patients shall be completed within a reasonable period of time specified in the medical staff by-laws, but not to exceed 30 days after discharge, excepting autopsy reports.

F. Maternity Patient Records.

(1) Prenatal findings: Except in an emergency, before a maternity patient may be admitted to a hospital, a legible copy of the prenatal history shall be submitted to the hospital's obstetrical staff. The prenatal history shall note complication, Rh determination and other matters essential to adequate care.

(2) Maternal medical record: Each obstetric patient shall have a complete hospital record, which shall include:

(a) patient identification, prenatal history and findings;

(b) the labor and delivery record, including anesthesia;

(c) medicine and treatment sheet, including nursing notes;

(d) any laboratory and x-rays reports;

(e) any medical consultant's notes; and

(f) an estimate of blood loss.

G. Newborn Medical Records. Each newborn patient shall have a complete hospital record which shall include:

(1) a record of pertinent material data, type of labor and delivery, and the condition of the infant at birth;

(2) a record of physical examinations;

(3) progress sheets to include medicine, treatment, weights, feeding and temperatures; and

(4) the notes of any medical consultant.

H. Fetal Death. In the case of a fetal death, the weight and length of the fetus shall be recorded on the delivery record.

I. Authentication of all Entries.

(1) Documentation.

(a) All entries in medical records by hospital staff and medical staff shall be legible, permanently recorded, dated and authenticated with the name and title of the person making the entry.

(b) All orders shall be recorded and authenticated. All verbal and telephone orders shall be authenticated by the prescribing practitioner, or a practitioner authorized to sign on behalf of the prescribing physician, in writing within 72 hours.

(c) A rubber stamp reproduction of a person's signature or an electronic signature may be used instead of a handwritten signature, if: the stamp is used only by the person whose signature the stamp replicates, the facility possesses a statement signed by the person, certifying that only that person(s) shall possess and use the stamp.

(2) Symbols and abbreviations:Symbols and abbreviations may be used in medical records if approved by a written facility policy, which defines the symbols and abbreviations and controls their use. There shall be only one meaning per symbol.

N.M. Code R. § 7.7.2.30

7.7.2.30 NMAC - Rp, 7.7.2.30 NMAC, 06-15-04; 7.7.2.30 NMAC - Rn, 7.7.2.29 NMAC & A, 03-15-06