Utah Admin. Code 432-101-33

Current through Bulletin 2024-23, December 1, 2024

Section R432-101-33 - Medical Records

(1) The licensee shall ensure medical records additionally comply with Section R432-100-34.

(2) The license shall ensure that patient records contain:

(a) a description of physical, social, and mental health status at the time of admission;

(b) a description of services provided;

(c) a description of progress reports;

(d) status at the time of discharge; and

(e) data on standardized forms that includes:

(i) patient name;

(ii) home address;

(iii) date of birth;

(iv) gender;

(v) next of kin;

(vi) marital status; and

(vii) date of admission;

(f) involuntary commitment status, including relevant legal documents;

(g) date the information was gathered, and names and signatures of the staff members gathering the information;

(h) signed orders by physicians and other authorized practitioners for medications and treatments;

(i) relevant physical examination, medical history, and physical and mental diagnoses using a recognized diagnostic coding system;

(j) information on any unusual occurrences, such as treatment complications, accidents, or injuries to or inflicted by the patient, and procedures that place the patient at risk;

(k) documentation of patient and family involvement in the treatment program;

(l) progress notes written by the psychiatrist, psychologist, social worker, nurse, and others significantly involved in active treatment;

(m) temperature, pulse, respirations, blood pressure, height, and weight notations, when indicated;

(n) reports of laboratory, radiologic, or other diagnostic procedures, and reports of medical or surgical procedures when performed;

(o) correspondence with signed and dated notations of telephone calls concerning the patient's treatment;

(p) a written plan for discharge including an assessment of patient needs;

(q) documentation of any instance when the patient was absent from the hospital without permission; and

(r) the patient care plan.

(3) The licensee shall ensure there is a discharge summary signed by the attending member of the medical staff and entered into the patient record within 30 calendar days from the date of discharge. In the event a patient dies, the licensee shall ensure the discharge statement includes a summary of events leading to the death.

(4) The licensee shall ensure the patient record contains evidence of informed consent or the reason it is unattainable.

(5) The licensee shall ensure the patient record contains consent for release of information, the date the information was released, and the signature of the staff member who released the information and evidence the patient was informed of the release of information as soon as possible.

(6) The licensee may release pertinent information to personnel responsible for the individual's care without the patient's consent under the following circumstances:

(a) in a life-threatening situation;

(b) when an individual's condition or situation precludes obtaining written consent for release of information;

(c) when obtaining written consent for release of information would cause an excessive delay in delivering essential treatment to the individual.

Utah Admin. Code R432-101-33

Amended by Utah State Bulletin Number 2023-22, effective 11/1/2023