Haw. Code R. § 11-99-28 - Resident record system
(a) There shall be
available sufficient, appropriately qualified staff and necessary supporting
personnel to facilitate the accurate processing, checking, indexing, filing,
and prompt retrieval of records and record data.
(b) If the supervisor of medical records is
not a registered records administrator, or accredited record technician, there
must be qualified consultation available.
(c) The following information shall be
obtained and entered in the resident's record at the time of admission to the
facility:
(1) Identifying information such
as: name, date, and time of admission, date and place of birth, citizenship
status, marital status, Social Security number or an admission number which can
be used to identify the resident without use of name when the latter is
desirable.
(2) Name and address of
next of kin or legal guardian.
(3)
Sex, height, weight, and identifying marks.
(4) Reason for admission or
referral.
(5) Language spoken or
understood.
(6) Information
relevant to religious affiliation.
(7) Admission diagnosis, summary of prior
medical care, recent physical examination, tuberculosis status, and physician's
orders.
(8) Pre-admission
evaluations completed by an interdisciplinary team not more than three months
prior to admission.
(d)
Records during stay at the facility shall include:
(1) Appropriate authorizations and
consents.
(2) Records of all
periods of restraints with justification and authorization for each.
(3) Copies of initial and periodic
examinations, evaluations, and progress notes.
(4) Regular review of the active treatment
program in an overall plan of care setting for the goals to be accomplished
through individually designed activities, therapies and treatments, and
indicating which professional services or individuals are responsible for
providing the care or service.
(5)
Entries describing treatments, medications, tests, and all ancillary services
rendered.
(6) Annual re-evaluations
by relevant professional services.
(e) When a resident is transferred to another
facility or discharged, there shall be:
(1)
Written evidence of the reason.
(2)
Except in an emergency, documentation to indicate that the resident understood
the reason for transfer, or that the guardian and family were
notified.
(3) A complete summary
including current status and care, final diagnosis, and prognosis.
(f) There shall be a master
alphabetical index of all residents admitted to the facility.
(g) All entries in the resident's record
shall be:
(1) Legible and typed or written in
ink.
(2) Dated.
(3) Authenticated by signature and title of
the individual making the entry.
(4) Written completely without the use of
abbreviations except for those abbreviations approved by a medical
consultant,
(h) All
information contained in a resident's record, including information contained
in an automated data bank, shall be considered confidential.
(i) The record shall be the property of the
facility, whose responsibility shall be to secure the information against loss,
destruction, defacement, tampering, or use by unauthorized persons.
(j) There shall be written policies governing
access to, duplication of, and dissemination of information from the
record.
(k) Written consent of the
resident, if competent, or the guardian shall be required for the release of
information to persons not otherwise authorized to receive it. Consent forms
shall include:
(1) Use for which requested
information is to be used.
(2)
Sections or elements of information to be released.
(3) Consent of resident or legal guardian for
release of medical record information. This consent shall include the dates
during which the consent is operable.
(l) Records shall be readily accessible and
available to authorized department personnel.
Notes
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