§11-96-24 - Health record system.

§11-96-24 Health record system.

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

(b) The following information shall be obtained and entered in the clients' record at the time of admission to the center:

(1) Identifying information such as: date of admission, date of birth, marital status, social security number or an admission

number which can be used to identify the client without use of name when the latter is desirable;

(2) Name and address of next of kin or legal guardian or care taker;

(3) Sex, height, weight, race, language spoken and understood; and

(4) Admission diagnosis, summary of prior medical care, recent physical examination,to include functional, cognitive, tuberculosis status, and physician's orders as described in section 11-96-5.

(c) Records during stay shall also include:

(1) Appropriate authorization and consents for medical procedures;

(2) Records of all periods of restraints with justification and authorization for each;

(3) Copies of initial and periodic examinations and evaluations, as well as progress notes at appropriate intervals;

(4) Annual review of an overall plan of care setting forth goals to be accomplished through individually designed activities, therapies, and treatments, and indicating which professional service or individual is responsible for providing the care or service;

(5) Entries describing treatments, medications, tests, ancillary services rendered; and

(6) Documentation of any injuries or accidents;

(d) When a client is discharged, there shall be a discharge summary which shall include:

(1) The reason for discharge;

(2) Except in an emergency, documentation to indicate that the client understood the reason for discharge, or that the guardian and family were notified; and

(3) A summary of current status and care, final diagnosis, and prognosis.

(e) There shall be a master alphabetical index of all clients admitted to the center.

(f) All entries in the clients' record shall be:

(1) Legible, typed, or written in ink;

(2) Dated; and

(3) Authenticated by signature and title of the individual making the entry.

(g) All information contained in a client's record, including any information contained in an automated data bank, shall be considered confidential.

(h) The record shall be the property of the center, whose responsibility shall be to secure the information against loss, destruction, defacement, tampering, or use by unauthorized persons.

(i) There shall be written policies governing access to, duplication of, and dissemination of information from the record. Written consent of the client, if competent, or the guardian if the client is not competent, 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 and specific periods of time during which the information is to be released; and

(3) Consent of client, or legal guardians, for release of specific health record information.

(j) Records shall be readily accessible and available to authorized department personnel for the purpose of determining compliance with this chapter.

(k) If a client has been absent for thirty days or more because of illness, there must be a written statement by a physician that the client is well enough to be readmitted to the program.

        [Eff ] (Auth: HRS §321-11) (Imp: HRS §321-11)

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