Iowa Admin. Code r. 481-51.10 - Records and reports
(1)
Medical
records. Accurate and complete medical records shall be maintained for
all patients and signed by the appropriate provider. These records shall be
filed and stored in an accessible manner and in accordance with the statute of
limitations as specified in Iowa Code chapter 614.
(2)
Hospital records. A
hospital shall maintain the following records:
a.
Admission records. A register of
all admissions to the hospital .
b.
Death records. A record of all deaths in the hospital ,
including all information on a standard death certificate as specified in Iowa
Code chapter 144.
c.
Birth
records. A record of all births in the hospital , including all
information on a standard birth certificate as specified in Iowa Code chapter
144.
d.
Controlled
substance records. Controlled substance records in accordance with
state and federal laws, rules and regulations.
(3)
Electronic records. In addition
to the access provided in 481-subrule 50.10(2), an authorized representative of
the department shall be provided unrestricted access to electronic records
pertaining to the care provided to the patients of the hospital .
a. If access to an electronic record is requested by
the authorized representative of the department, the hospital may provide a
tutorial on how to use its particular electronic system or may designate an
individual who will, when requested, access the system, respond to any
questions or assist the authorized representative as needed in accessing
electronic information in a timely fashion.
b. The hospital shall provide a terminal where the
authorized representative may access records.
c. If the hospital is unable to provide direct print
capability to the authorized representative, the hospital shall make available
a printout of any record or part of a record on request in a time frame that
does not intentionally prevent or interfere with the department's survey or
investigation.
Notes
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