Section 410IAC15-1.5-4. Medical record services

 

                (a) The medical record service has administrative responsibility for the medical records that shall be maintained for every individual evaluated or treated within those services that come under the hospital's license.

                (b) The organization of the medical record service shall be appropriate to the scope and complexity of the services provided as follows:

(1) The service shall be directed by a registered health information administrator (RHIA) or a registered health information technician (RHIT). If a full-time or part-time RHIA or RHIT is not employed, then a consultant RHIA or RHIT shall be provided to assist the person in charge. Documentation of the findings and recommendations of the consultant shall be maintained.

(2) The medical record service shall be provided with the necessary direction, staffing, and facilities to perform all required functions in order to ensure prompt completion, filing, and retrieval of records.

                (c) An adequate medical record shall be maintained with documentation of service rendered for each individual who is evaluated or treated as follows:

(1) Medical records are documented accurately and in a timely manner, are readily accessible, and permit prompt retrieval of information.

(2) A unit record system of filing should be utilized. When this is not possible, a system shall be established by the hospital to retrieve when necessary all divergently located record components.

(3) The hospital shall use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. Each entry shall be authenticated promptly in accordance with the hospital and medical staff policies.

(4) Medical records shall be retained in their original or legally reproduced form as required by federal and state law.

(5) Plain paper facsimile orders, reports, and documents are acceptable for inclusion in the medical record if allowed by the hospital policies.

(6) The hospital shall have a system of coding and indexing medical records which allows for timely retrieval of records by diagnosis and procedure in order to support continuous quality assessment and improvement activities.

(7) The hospital shall ensure the confidentiality of patient records which includes, but is not limited to, the following:

(A) A procedure for releasing information from or copies of records only to authorized individuals in accordance with federal and state laws.

(B) A procedure that ensures that unauthorized individuals cannot gain access to patient records.

                (d) The medical record shall contain sufficient information to:

(1) identify the patient;

(2) support the diagnosis;

(3) justify the treatment; and

(4) document accurately the course of treatment and results.

                (e) All entries in the medical record shall be:

(1) legible and complete;

(2) made only by individuals given this right as specified in hospital and medical staff policies; and

(3) authenticated and dated promptly in accordance with subsection (c)(3).

                (f) All inpatient records, except those in subsection (g), shall document and contain, but not be limited to, the following:

(1) Identification data.

(2) The medical history and physical examination of the patient done within the time frames as prescribed by the medical staff rules and section 5(b)(3)(M) of this rule.

(3) A statement of the diagnosis or impressions drawn from the admission history and physical examination.

(4) Diagnostic and therapeutic orders.

(5) Evidence of appropriate informed consent for procedures and treatments for which it is required as specified by the informed consent policy developed by the medical staff and governing board, and consistent with federal and state law.

(6) Clinical observations, including results of therapy, documented in a timely manner.

(7) Progress notes.

(8) Operative note in accordance with 410 IAC 15-1.6-9(c)(7).

(9) Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient.

(10) Nursing notes, nursing plan of care, and entries by other health care providers that contain pertinent, meaningful observations and information.

(11) Reports of pathology and clinical laboratory examinations, radiology and nuclear medicine examinations or treatment, anesthesia records, and any other diagnostic or therapeutic procedures and their results.

(12) Documentation of complications and unfavorable reactions to drugs and anesthesia.

(13) A discharge summary authenticated by the physician. A final progress note may be substituted for the discharge summary in the case of a normal newborn infant and uncomplicated obstetric delivery. The final progress note should include any instruction given to the patient and family.

(14) Final diagnosis.

                (g) A short stay record form used for inpatients hospitalized for less than forty-eight (48) hours, observation patients, ambulatory care patients, and ambulatory surgery patients shall document and contain, but not be limited to, the following:

(1) Identification data.

(2) Medical history and description of the patient's condition and pertinent physical findings.

(3) Diagnostic and therapeutic orders.

(4) Care based on identified standard of care and standard of practice.

(5) Data necessary to support the diagnosis and the treatment given, with reports of procedures and tests, and their results, clinical observations, including the results of therapy, and anesthesia given, if applicable.

(6) Operative note in accordance with 410 IAC 15-1.6-9(c)(7), if applicable.

(7) Final progress note, including instructions to the patient and family with dismissal diagnosis and disposition of patient.

(8) Authentication by the physician and other responsible personnel in attendance.

                (h) Outpatient records shall document and contain, but not be limited to, the following:

(1) Identification data.

(2) Diagnostic and therapeutic orders.

(3) Description of treatment given, procedures performed, and documentation of patient response to intervention, if applicable.

(4) Results of diagnostic tests and examinations done, if applicable.

                (i) Emergency service records shall document and contain, but not be limited to, the following:

(1) Identification data.

(2) Time of arrival, means of arrival, time treatment is initiated, and time examined by the physician, if applicable.

(3) Pertinent history of illness or injury, description of the illness or injury, and examination, including vital signs.

(4) Diagnostic and therapeutic orders.

(5) Description of treatment given or prescribed, clinical observations, including the results of treatment, and the reports of procedures and test results, if applicable.

(6) Authentication by the practitioner or licensed health professional who rendered treatment or prescribed for the patient in accordance with hospital policy.

(7) Instruction given to patient on release, prescribed follow-up care, signature of patient or responsible other, and name of person giving instructions.

(8) Diagnostic impression and condition on discharge documented by the practitioner, and disposition of the patient and time of dismissal.

(9) Copy of transfer form, if patient is referred to the inpatient service of another hospital. If care is not furnished to a patient or if the patient is referred elsewhere, the reasons for such action shall be recorded.

(Indiana State Department of Health; 410 IAC 15-1.5-4; filed Dec 21, 1994, 9:40 a.m.: 18 IR 1269; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; filed Jan 2, 2003, 10:22 a.m.: 26 IR 1550; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; readopted filed Jul 14, 2011, 11:42 a.m.: 20110810-IR-410110253RFA)