§11-95-20 - Medical records

§11-95-20 Medical records.

(a) There shall be available sufficient, appropriate qualified staff and necessary supporting personnel to facilitate the accurate processing, checking, indexing, filing, and prompt retrieval of records and record data.

(b) All patient records shall be considered confidential and the property of the facility which shall secure them against loss, destruction, defacement, tampering, or use by unauthorized persons.

(c) Patient records shall contain, but not necessarily be limited to, the following information:

(1) Prior to surgery, the patient record shall contain the following:

(A) Sufficient history, physical examination, x-ray and laboratory data to support the admitting diagnosis and the decision to carry out the proposed procedure;

(B) Sufficient history, physical examination, and laboratory data to support the decision as to which anesthetic techniques and medications are to be used during the procedure;

(C) Results of all pertinent consultation reports, laboratory and x-ray reports shall be recorded on the chart by the patient's physician. Originals or photocopies of the originals shall be on the chart within forty-eight hours of admission to the facility;

(D) Documentation that sufficient attention has been given to:

(i) Preventing and preparing for the customary complications of the proposed surgical procedure and the proposed anesthetic procedure; (ii) Preventing and preparing for any special hazards confronting a particular patient;

(E) An informed consent form shall be signed by the patient or the patient's guardian, or patient's parents, and be filed in the chart;

(2) Within forty-eight hours following surgery, the patient's record shall contain:

(A) An operative note which shall clearly indicate what was found and what was

done;

(B) An anesthetic note which shall specify the anesthetic techniques and medications used, as well as dosages of the medications. It shall also contain the result of appropriate physiological monitoring during the anesthetic induction, maintenance and recovery period. A record of any untoward development during this period shall also be noted;

(C) All medications given to or taken by the patient shall be properly recorded in respect to time given, dose, and any response noted;

(3) A discharge note including the final diagnosis at the time of discharge;

(4) A copy of the discharge document required in section 11-95-25(d).

(d) A daily log with monthly summaries of all procedures performed and the disposition of all patients shall be kept by the facility.

        [Eff March 3, 1986] (Auth: HRS §§321-9, 321-10) (Imp: HRS §321-10)

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