Haw. Code R. § 11-99-78 - 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 regularly scheduled visits by a qualified consultant who shall provide
reports to the administrator.
(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) Preadmission
evaluations completed by an interdisciplinary team not more than three months
prior to admission.
(d)
Records during stay at the facility shall also 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 forth goals to be accomplished
through individually designed activities, therapies and treatments, and
indicating which professional services or individual is responsible for
providing the care or service.
(5)
Entries describing treatments, medications, tests, and all ancillary services
rendered.
(6) Annual re-evaluations
by all professional services including at least a physician, dentist,
psychologist, social worker, and nurse.
(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) 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
or the medical director.
(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 any medical record
information. This consent shall include the dates during which this consent is
operable.
(l) Records
shall be readily accessible and available to authorized department
personnel.
Notes
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