Utah Admin. Code 432-200-29

Current through Bulletin 2024-20, October 15, 2024

Section R432-200-29 - Medical Records

(1) The licensee shall ensure the organization of medical records complies with the following:

(a) records are complete, accurately documented, and systematically organized to facilitate retrieval and compilation;

(b) there are written policies and procedures to accomplish these purposes;

(c) the medical record service is under the direction of a registered record administrator (RRA) or an accredited record technician (ART);

(d) if an RRA or an ART is not employed at least part-time by the licensee, the licensee consults at least annually with an RRA or ART according to the needs of the facility; and

(e) a designated individual oversees day-to-day record keeping.

(2)

(a) The licensee shall ensure that record retention and storage practices are compliant with this subsection.

(b) The licensee shall provide for the filing, safe storage, and easy accessibility of medical records.

(c) The licensee shall ensure records and their contents are safeguarded from loss, defacement, tampering, fires, and floods.

(d) The licensee shall ensure records are protected against access by unauthorized individuals.

(e) The licensee shall ensure records are retained for at least seven years after the last date of resident care.

(f) The licensee shall retain records of minors until the minor reaches age 18 or the age of majority plus an additional two years.

(g) A licensee may not retain a record for any less than seven years.

(h) The licensee shall ensure each resident record is retained within the facility upon change of ownership.

(i) When a facility ceases operation, the licensee provides appropriate, safe storage and prompt retrieval of any medical records.

(3)

(a) The licensee shall ensure that release of information practices are compliant with this subsection.

(b) The licensee shall ensure there are written procedures for the use and removal of medical records and the release of information.

(c) The licensee shall ensure medical records remain confidential.

(d) The licensee shall ensure information is only disclosed to authorized individuals in accordance with federal, state, and local laws.

(e) The licensee shall ensure requests for other information that may identify the resident, including photographs requires the written consent of the resident, or guardian if the resident is judged incompetent.

(4) Authorized representatives of the department may review records to determine compliance with licensure rules and standards.

(5) The licensee may allow rubber-stamp signatures in lieu of the written signature of the physician or licensed practitioner, if the facility retains the signatory's signed statement acknowledging ultimate responsibility for the use of the stamp and specifying the conditions for its use.

(6) The licensee shall ensure that medical records:

(a) are permanently typewritten or hand written legibly in ink, and capable of being photocopied;

(b) are maintained for each resident admitted or accepted for treatment and care;

(c) are current and conform to medical and professional practices based on the service provided to each resident;

(d) are completed and filed within 60 days of each client's discharge; and

(e) are authenticated including date, name or identified initials, and title of each person making each entry.

(7) The licensee shall maintain an individual medical record for each resident that includes:

(a) an admission record face sheet that identifies the following resident information:

(i) name;

(ii) social security number;

(iii) age at admission;

(iv) birth date;

(v) date of admission;

(vi) name, address, telephone number of spouse, guardian, authorized representative, person or agency responsible for the resident; and

(vii) name, address, and telephone number of the attending physician;

(b) admission and subsequent diagnoses and any allergies;

(c) reports of physical examinations signed and dated by the physician;

(d) signed and dated physician orders for drugs, treatments, and diet; and

(e) signed and dated progress notes that include:

(i) staff records regarding the daily care of the resident;

(ii) informative progress notes that describe the resident's needs and responses to care and treatment in accordance with the plan of care that are written by any staff recording changes in the resident's condition;

(iii) documentation of administration of any as-needed medications and the reason for withholding any scheduled medications;

(iv) documentation of use of restraints in accordance with facility policy including type of restraint, reason for use, time of application, and removal;

(v) documentation of oxygen administration;

(vi) temperature, pulse, respiration, blood pressure, height, and weight notations, when required;

(vii) laboratory reports of any tests prescribed and completed;

(viii) reports of any x-rays prescribed and completed;

(ix) records of the course of any therapeutic treatments;

(x) discharge summary that includes a brief narrative of conditions and diagnoses of the resident and final disposition;

(xi) a copy of the transfer form when the resident is transferred to another health care facility; and

(xii) resident care plan.

Utah Admin. Code R432-200-29

Amended by Utah State Bulletin Number 2024-03, effective 1/22/2024