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19a-14-40. Medical records, definition, purpose
The purpose of a medical record is to provide a vehicle for: documenting actions taken in patient management; documenting patient progress; providing meaningful medical information to other practitioners should the patient transfer to a new provider or should the provider be unavailable for some reason. A medical record shall include, but not be limited to, information sufficient to justify any diagnosis and treatment rendered, dates of treatment, actions taken by non-licensed persons when ordered or authorized by the provider; doctors' orders, nurses notes and charts, birth certificate work-sheets, and any other diagnostic data or documents specified in the rules and regulations. All entries must be signed by the person responsible for them.
(Effective August 29, 1984.)
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The medical record shall include, at a minimum, the following items (if applicable):
A. Identification information, which include but are not limited to the following:
Name.
1) Address on admission.
2) Identification number (if applicable).
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Compliance with the above policy is monitored by UC__ Department of ________. Violations of any of the above policy will be reported to the appropriate supervising authority for potential disciplinary action, up to and including termination and/or restriction of privileges in accordance with UC__ Medical Staff ByLaws, and Human Resource / Personnel Policies.
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The following three categories of data contain secondary patient information and must be afforded the same level of confidentiality as the LMR, but are not considered part of the legal medical record.
A. Patient-identifiable source data are data from which interpretations, summaries, notes, etc. are derived. They often are maintained at the department level in a separate location or database, and are retrievable only upon request.
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A. Electronic signatures must meet standards for:
1. Data integrity to protect data from accidental or unauthorized change (for example “locking” of the entry so that once signed no further untracked changes can be made to the entry);
2. Authentication to validate the correctness of the information and confirm the identity of the signer (for example requiring signer to authenticate with password or other mechanism);
3. Non-repudiation to prevent the signer from denying that he or she signed the document (for example, public/private key architecture).
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When an error is made in a medical record entry, the original entry must not be obliterated, and the inaccurate information should still be accessible.
The correction must indicate the reason for the correction, and the correction entry must be dated and signed by the person making the revision. Examples of reasons for incorrect entries may include “wrong patient,” etc. The contents of Medical Records must not otherwise be edited, altered, or removed. Patients may request a medical record amendment and/or a medical record addendum. (Refer to UC__ policy for handling patient requests for record amendment and record addendums.)
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All Medical Records are retained for at least as long as required by State and federal law and regulations, and UC__ policies and procedures (see: “Records Retention” and No. ____, “Records Storage and Destruction”). The electronic version of the record must be maintained per the legal retention requirements as specified in Policy No. _____ (UC Campus) “Record Retention” or consult with Campus Legal Counsel.
A. In the event that an original Medical Record cannot be located, a temporary medical record folder will be created as follows:
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