Utah Admin. Code R432-153-14 - Medical Records
(1) The facility
shall retain, store and safeguard the client medical record and its
contents.
(2) The facility shall
protect the client medical record against access by unauthorized
individuals.
(3) The facility shall
retain the client medical record for at least seven years. Medical records of
minors shall be kept until the age of 18 plus four years, but in no case less
than seven years.
(4) The facility
shall maintain a record for each client receiving respite services that
includes:
(a) the assessment and service
agreement;
(b) demographic
information and client identification data;
(c) contact information for the responsible
party;
(d) nursing notes;
(e) physician treatment orders;
(f) records made by staff regarding daily
care of the client in service; and
(g) a post-service summary.
Notes
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