048-17 Wyo. Code R. §§ 17-15 - Medical Records

(a) The facility shall maintain a medical records system in accordance with written policies and procedures.

(i) Professional standards of practice for medical records shall be met.

(ii) A medical record shall be created and maintained for each patient receiving health care services that includes, if applicable:

(A) Identification and social data;

(B) Admitting diagnosis;

(C) Pertinent medical history;

(D) Properly executed consent forms;

(E) Reports of physical examinations, diagnostic and laboratory test results, and consultation findings;

(F) All physicians' orders, nurses' notes, and reports of treatment and medications;

(G) Final diagnosis;

(H) Discharge summary; and

(I) Any other pertinent information necessary to monitor the patient's prognosis.

(iii) Each record shall include the signatures of the physician and the health care professional's documentation.

(iv) Records of a discharged patient shall be completed within fifteen (15) days of the discharge date.

(v) The facility shall have written policies and procedures ensuring the confidentiality of patient records, safeguards against loss, destruction, or unauthorized use, in accordance with applicable state and federal laws. These policies and procedures shall:

(A) Govern the use and removal of records from the record storage area;

(B) Specify the conditions under which record information may be released and to whom; and

(C) Specify when the patient's written consent is required for release of information.

Notes

048-17 Wyo. Code R. §§ 17-15

Amended, Eff. 3/1/2023.