Section 440IAC1.5-3-6. Medical record services

   (a) The facility shall:

(1) maintain a written clinical record on every consumer; and

(2) have policies and procedures for clinical record organization and content.

  (b) The services must be directed by:

(1) a registered health information administrator (RHIA); or

(2) an accredited health information technician (RHIT).

If a full-time or part-time RHIA or RHIT is not employed, then a consultant RHIA or RHIT must be provided to assist the person in charge. Documentation of the findings and recommendations of the consultant must be maintained.

  (c) The unit record system shall be used to assure that the maximum possible information about a consumer is available. The consumer's record shall contain pertinent information, which, at a minimum, shall consist of the following:

(1) A face sheet (identification data).

(2) Referral information.

(3) A database (assessment information).

(4) An individual treatment plan.

(5) History and physical exams.

(6) Orders of a physician, licensed mental health professional, and LIP.

(7) Medication and treatment record.

(8) Progress notes.

(9) Treatment plan reviews.

(10) Special dietetic information.

(11) Consultation reports.

(12) Correspondence.

(13) Legal or commitment documents.

(14) A discharge or separation summary.

(15) Release or aftercare plans.

  (d) The record shall contain identifying data in accordance with the policy of the facility.

  (e) The consumer record shall contain information of any unusual occurrences, such as the following:

(1) Treatment complications.

(2) Accidents or injuries to the consumer.

(3) Morbidity.

(4) The death of a consumer.

(5) Procedures that place a consumer at risk or cause unusual pain.

  (f) All entries in the consumer record shall be signed and dated.

  (g) Symbols and abbreviations shall be used only:

(1) if they have been approved by the medical or professional staff; and

(2) when an explanatory legend is provided.

Symbols and abbreviations shall not be used in the recording of a diagnosis.

  (h) The facility shall be responsible for the following:

(1) Maintenance, control, and supervision of consumer records.

(2) Maintaining the quality of medical record services.

  (i) The consumer record service shall establish, maintain, and control record completeness systems and mechanisms to ensure the quality and appropriateness of all documentation.

  (j) Written policies and procedures shall:

(1) govern the:

(A) compilation;

(B) storage;

(C) dissemination; and

(D) accessibility;

of consumer records; and

(2) be so designed as to assure that the facility fulfills its responsibility to protect the records against:

(A) loss;

(B) unauthorized alteration; or

(C) disclosure of information.

  (k) The consumer record shall be considered both a medical and legal document with careful consideration given to each entry in advance; therefore, the record may not be changed unless an error has been made or omission discovered with the correction process identified by policy and procedure.

  (l) The facility shall maintain an indexing or referencing system that can be used to locate a consumer record that has been removed from the central file area.

  (m) The facility shall have written policies and procedures that:

(1) protect the confidentiality of consumer records; and

(2) govern the disclosure of information in the records.

The records shall comply with all applicable federal, state, and local laws, rules, and regulations.

  (n) All original medical records or legally reproduced medical records must be:

(1) maintained by the facility for a period of seven (7) years;

(2) readily accessible, in accordance with the facility policy; and

(3) kept in a fire resistive structure.

(Division of Mental Health and Addiction; 440 IAC 1.5-3-6; filed Oct 11, 2002, 11:26 a.m.: 26 IR 740; filed Aug 11, 2008, 3:40 p.m.: 20080910-IR-440070875FRA; readopted filed Nov 5, 2008, 3:50 p.m.: 20081119-IR-440080742RFA; readopted filed Aug 11, 2014, 11:21 a.m.: 20140910-IR-440140240RFA)