Section R432-150-24 - Medical Records(1) The licensee shall implement a medical records system to ensure complete and accurate retrieval and compilation of information.(2)(a) The administrator shall designate an employee to be responsible and accountable for the processing of medical records.(b) The administrator shall ensure that a registered record administrator (RRA) or accredited record technician (ART) directs the medical records department.(c) If an RRA or ART is not employed at least part-time, the administrator shall consult with an RRA or ART according to the needs of the facility, and no less than semi-annually.(3) The licensee shall ensure resident medical records are:(a) retained, stored, and safeguarded from loss, defacement, tampering, and damage from fires and floods;(b) protected against access by unauthorized individuals; and(c) retained for at least seven years and medical records of minors are kept until the age of eighteen plus four years, but in no case less than seven years.(4) The licensee shall maintain an individual medical record for each resident that contains written documentation of the following:(a) records made by staff regarding daily care of the resident;(b) informative progress notes by staff to record changes in the resident's condition and response to care and treatment in accordance with the care plan;(c) a pre-admission screening;(d) an admission record with demographic information and resident identification data;(e) a history and physical examination up-to-date at the time of the resident's admission;(f) written and signed informed consent;(g) orders by clinical staff members;(h) a record of assessments, including the comprehensive resident assessment, care plan, and services provided;(j) monthly nursing summaries;(k) quarterly resident assessments;(l) a record of medications and treatments administered;(m) laboratory and radiology reports;(n) a discharge summary for the resident to include a note of condition, instructions given, and referral as appropriate;(o) a service agreement if respite services are provided;(p) physician treatment orders;(q) information pertaining to incidents, accidents, and injuries; and(r) a copy of an advanced directive, if a resident has one. (5) The licensee shall ensure any entries into the medical record are authenticated including date, name or identifier initials, and title of the person making the entries.(6) The licensee shall ensure resident respite records are maintained within the facility.Utah Admin. Code R432-150-24
Amended by Utah State Bulletin Number 2017-12, effective 5/16/2017Amended by Utah State Bulletin Number 2024-01, effective 12/12/2023