Utah Admin. Code R432-600-21 - Medical Records
(1) Medical records
shall be complete, accurately documented, and systematically organized to
facilitate storage and retrieval. There shall be written policies and
procedures to accomplish these purposes.
(2) A permanent individual medical record
shall be maintained for each patient.
(3) All entries shall be permanent and
capable of being photocopied. Entries must be authenticated including date,
name or identified initials, and title of the person making the
entry.
(4) Records shall be kept
for all patients admitted or accepted for treatment and care. Records shall be
kept current and shall conform to good medical and professional practice based
on the service provided to each patient.
(5) All records of discharged patients shall
be completed and filed as soon as possible or within 30 days of
discharge.
(6) Each patient's
medical record shall include the following:
(a) An admission record (face sheet)
including the patient's name; age; date of admission; name, address, and
telephone number of physician and responsible person;
(b) Reports of physical examinations,
laboratory tests and X-rays prescribed and completed, including ultrasound
reports;
(c) Signed and dated
physician orders for drugs and treatments;
(d) Signed and dated nurse's notes regarding
the care of the patient. The notes shall include vital signs, medications,
treatments and other pertinent information;
(e) Discharge summary which contains a brief
narrative of conditions and diagnoses of the patient and final
disposition;
(f) The pathologist's
report of human tissue removed during an abortion;
(g) All information indicated in Section
76-7-313.
(7) Medical records shall be
retained for at least seven years after the last date of patient care. Records
of minors shall be retained until the minor reaches age 18 or the age of
majority plus an additional two years. In no case shall the record be retained
less than seven years.
(8) All
patient records shall be retained within the clinic upon change of
ownership.
(9) Provision shall be
made for filing, safe storage, security, and easy accessibility of medical
records.
(10) Medical record
information shall be confidential. There shall be written procedures for the
use and removal of medical records and the release of patient information.
(a) Information may be disclosed only to
authorized persons in accordance with federal and state laws, and clinic
policy.
(b) Requests for
information which may identify the patient (including photographs) shall
require the written consent of the patient.
Notes
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