Section R432-100-35 - Medical Records(1) The licensee shall establish a medical records department or service that is responsible for the administration, custody, and maintenance of medical records. (a) The hospital administrator shall establish administrative direction of the medical records department and in accordance with the organizational structure and policies of the hospital.(b) The licensee shall retain the technical services of either a registered health information administrator or a registered health information technician through employment or consultation. If retained by consultation, the individual shall visit at least quarterly and document visits through written reports to the hospital administrator.(2) The licensee shall provide secure storage, controlled access, prompt retrieval, and equipment and facilities to review medical records. (a) The license shall ensure medical records are available for use or review by:(i) members of the medical and professional staff;(ii) authorized hospital personnel and agents;(iii) people authorized by the patient through a consent form; and(iv) department representatives to determine compliance with licensing rules.(b) Medical records may be stored in multiple locations if the record can be retrieved or accessed in a reasonable time period.(c) If computer terminals are utilized for patient charting, the licensee shall have policies governing access and identification codes, security, and information retention.(d) The licensee shall index a hospital medical record according to diagnosis, procedure, demographic information, and physician or licensed health practitioner and ensure the index is current within six months following discharge of the patient.(e) Original medical records are the property of the licensee and shall not be removed from the control of the licensee or the licensee's agent as defined by policy, except by court order or subpoena.(f) The licensee shall manage medical records for individuals who have received or requested admission to an alcohol or drug program in accordance with the Code of Federal Regulations, Title 42, Part 2, Confidentiality of Substance Use Disorder Patient Records.(3) The licensee shall ensure that any medical record entries are legible, complete, authenticated, and dated by the person responsible for ordering the service, providing, or evaluating the service, or making the entry. The author shall review prepared transcriptions of dictated reports, evaluations, and consultations before authentication.(a) The authentication may include written signatures, computer key, or other methods approved by the governing body and medical staff to identify the name and discipline of the person making the entry.(b) Use of computer key or other methods to identify the author of a medical record entry may not be assignable or delegated to another person.(c) The licensee shall maintain a current list of individuals approved to use the methods of authentication. Hospital policy shall identify sanctions for the unauthorized or improper use of computer codes.(d) Qualified personnel shall accept and transcribe verbal orders for the care and treatment of the patient and authenticate them within 30 days of the patient's discharge.(4) The licensee shall ensure medical records are organized according to hospital policy and the following: (a) medical records are reviewed at least quarterly for completeness, accuracy, and adherence to hospital policy;(b) records of discharged patients are collected, assembled, reviewed for completeness, and authenticated within 30 days of the patient's discharge;(c) medical records are retained for at least seven years and medical records of minors are kept until the age of 18 plus four years, but in no case less than seven years.(d) the licensee may destroy medical records after retaining them for the minimum period of time, and before destroying medical records, the licensee shall notify the public by publishing a notice in a newspaper of statewide distribution a minimum of once per week for three consecutive weeks to allow a former patient to access their records;(e) the licensee shall permanently retain a master patient or person index that shall include: (ii) the medical record number;(iv) the admission and discharge dates; and(v) the name of each attending physician.(f) if a licensee ceases operation, the licensee shall provide secure, safe storage and prompt retrieval of any medical records, patient indexes, and discharges for the period specified in Subsection R432-100-34(4)(c); and(g) the licensee may arrange for storage of medical records with another hospital, or an approved medical record storage facility, or may return patient medical records to the attending physician if the physician is still in the community.(5) The licensee shall establish and maintain a complete medical record for each patient admitted, or who receives hospital services. Emergency and outpatient medical records shall contain documentation of the service provided and other pertinent information in accordance with hospital policy.(6) The licensee shall ensure that each medical record contains: (a) patient identification and demographic information to include at least the patient's name, address, date of birth, sex, and emergency contact information;(b) initial or admitting medical history, physical and other examinations or evaluations. Recent histories and examinations may be substituted if updated to include changes that reflect the patient's current status;(c) admitting, secondary, and primary diagnoses;(d) results of consultative evaluations and findings by individuals involved in the care of the patient;(e) documentation of complications, hospital acquired infections, and unfavorable reactions to medications, treatments, and anesthesia;(f) properly executed informed consent documents for any procedures and treatments ordered for, and received by, the patient;(g) documentation that the facility requested of each admitted person whether the person has initiated an advanced directive as defined in the Title 75, Chapter 2a, Advance Health Care Directive Act;(h) practitioner orders, nursing notes, reports of treatment, medication records, laboratory and radiological reports, vital signs, and other information that documents the patient condition and status; and(i) a discharge summary including outcome of hospitalization, disposition of case with an autopsy report when indicated, or provisions for follow-up.(7) A medical record of a deceased patient shall contain a completed Inquiry of Anatomical Gift form or a modified hospital death form that has been approved by the department, as required by Title 26, Chapter 28, Revised Uniform Anatomical Gift Act.(8) A medical record of a surgical patient shall contain:(a) a pre-operative history and physical examination;(c) an operative report describing a description of findings;(d) an anesthesia report including dosage and duration of any anesthetic and pertinent events during the induction, maintenance, and emergence from anesthesia;(e) the technical procedures used;(f) the specimen removed;(g) the post-operative diagnosis;(h) the name of the primary surgeon; and(i) assistants written or dictated by the surgeon within 24 hours after the operation.(9) A medical record of an obstetrical patient shall contain:(a) a relevant family history;(b) a pre-natal examination;(c) the length of labor and type of delivery with related notes;(d) the anesthesia or analgesia record;(e) the Rh status and immune globulin administration when indicated;(f) a serological test for syphilis; and(g) a discharge summary for complicated deliveries or final progress note for uncomplicated deliveries.(10) A Medical record of a newborn infant shall contain the following documentation in addition to the requirements for obstetrical medical records: (a) a copy of the mother's delivery room record. In adoption cases where the identity of the mother is confidential, the licensee shall include and access the mother's according to hospital policy;(b) the date and hour of birth;(e) reactions after birth;(g) temperature and weight;(h) time of first urination; and(i) number, character, and consistency of stools;(j) a record of the physical examination completed at birth and discharge, record of ophthalmic prophylaxis, and the identification number of the newborn screening kit, referred to in Rule R398-1;(k) the authorization by the parents, state agency, or court authority if the infant is discharged to any person other than the infant's parents; and(l) the record and results of the newborn hearing screening according to Sections 26B-1-432 and R398-2-6.(11) The licensee shall integrate an emergency department patient medical record into the hospital medical record, that includes;(a) time and means of arrival;(b) emergency care given to the patient before arrival;(c) history and physical findings;(d) lab and x-ray reports;(f) record of treatment; and(g) disposition and discharge instructions.(12) A medical -social services patient record shall include: (a) a medical-social or psychosocial study of a referred inpatient and outpatient;(b) the financial status of the patient;(c) social therapy and rehabilitation of the patient;(d) an environmental investigation for an attending physician; and(e) any cooperative activities with community agencies.(13) A medical record of a patient receiving rehabilitation therapy shall include: (a) a written plan of care appropriate to the diagnosis and condition;(c) short and long term goals.(14) The medical records department shall maintain records, reports and documentation of admissions, discharges, and the number of autopsies performed.(15) The medical records department shall maintain vital statistic registries for births, deaths, and the number of operations performed. The medical records department shall report vital statistics data in accordance with the Title 26B, Chapter 8, Vital Statistics Act.Utah Admin. Code R432-100-35
Amended by Utah State Bulletin Number 2016-5, effective 2/10/2016Amended by Utah State Bulletin Number 2023-14, effective 7/6/2023