Okla. Admin. Code § 310:663-19-3

Current through Vol. 42, No. 7, December 16, 2024

Section 310:663-19-3 - Maintenance of records

(a) There shall be an organized, accurate, clinical record, typewritten, electronic, or legibly written with pen and ink, for each resident admitted. The resident's record shall document all services provided under the direction of a licensed health care professional consistent with professional standards of practice.

(b) Each resident's records shall be retained for at least five (5) years after the resident's transfer, discharge or death. Destruction of records shall be done in a manner to preserve resident confidentiality.

(c) Records for the previous twelve (12) months of operation, whether original, electronic, or microfilm copies, shall be maintained in such form as to be legible and readily available upon request of the attending physician, the assisted living center and any person authorized by law to make such a request. Records more than twelve (12) months old, whether original, electronic, or microfilm copies, shall be maintained in such form as to be legible and available within seventy-two (72) hours upon request of the attending physician, the continuum of care facility or assisted living center, and any person authorized by law to make such a request.

(d) Information contained in each resident's record shall be confidential and disclosed only to the resident, persons authorized by the resident, and persons authorized by law or rule.

(e) Resident records shall be filed and stored to protect against loss, destruction, or unauthorized use.

(f) The Department shall be informed in writing within five (5) business days of discovery whenever any resident's records are defaced, or destroyed, before the end of the required retention period.

(g) If an assisted living center ceases operation, the Department shall be notified within five (5) business days of the arrangements for preserving the resident's record. The record shall be preserved for the required time and the information in the records shall be available to the health professionals or facilities assuming care of the resident so that continuity of care is available.

(h) If the ownership of the assisted living center changes, the new licensee shall have custody of original or true and correct copies of all records required by this section for all current residents and the records shall be available to the former licensee and other authorized persons.

(i) Incident reports required in 310:663-19-1. shall be retained, filed and stored to protect against loss, destruction, or unauthorized use for a period of two (2) years. Destruction of incident reports shall be done in a manner to preserve resident confidentiality.

Okla. Admin. Code § 310:663-19-3

Added at 24 Ok Reg 2007, eff 6-25-07¹; Amended at 25 Ok Reg 2460, eff 7-11-08

¹See Editor's Note at beginning of this Chapter.