SECTION 1101 Physician’s Responsibility

It shall be the responsibility of each physician to complete and authenticate the medical record within a stipulated time after discharge, not to exceed 30 days after discharge. 

HISTORY: Amended by State Register Volume 38, Issue No. 6, Doc. No. 4430, eff June 27, 2014.

SECTION 1102 Organization

The responsibility for supervision, filing, indexing, maintenance and storage of medical records shall be assigned to a responsible employee of the hospital who has had training in this field. 

HISTORY: Amended by State Register Volume 38, Issue No. 6, Doc. No. 4430, eff June 27, 2014. 

SECTION 1103 Indexing

Medical records shall be properly indexed, organized, filed and ready for access by members of the staff.

HISTORY: Amended by State Register Volume 38, Issue No. 6, Doc. No. 4430, eff June 27, 2014.

SECTION 1104 Ownership

Medical records of patients are the property of the organization and must not be released from the hospital’s authority or control except by court order.

HISTORY: Amended by State Register Volume 38, Issue No. 6, Doc. No. 4430, eff June 27, 2014.

SECTION 1105 Contents

A. Each entry in the medical records must be legible, dated, timed and signed/authenticated by the clinician or designee that created the entry. A medical record must be created for all patients admitted to the hospital and newborns delivered in the hospital. Initials will be accepted provided such initials can be readily identified within the medical record. A minimum medical record shall include the following information:

1. An admission record must be prepared for each patient and must contain the following information, when obtainable: Name; address, including county; occupation; age; date of birth; sex; marital status; religion; county of birth; father’s name; mother’s maiden name; husband’s or wife’s name; dates of military service; health insurance number; provisional diagnosis; case number; days of care; social security number; the name of the person providing information; name, address and telephone number of person or persons to be notified in the event of emergency; name and address of referring physician; name and address and telephone number of attending physician; date and hour of admission;

2. History and physical within 48 hours after admission;

3. Provisional or working diagnosis;

4. Preoperative diagnosis;

5. Plan of care;

6. Complete surgical record, if any, including technique of operation and findings, statement of tissue and organs removed and postoperative diagnosis;

7. Report of anesthesia;

8. Nurses’ notes;

9. Progress notes;

10. Gross pathological findings and microscopic, if applicable;

11. Vital signs and other measurements appropriate to patient;

12. Medication Administration Record or similar document for recording of medications, treatments and other pertinent data. This record shall be signed/authenticated after each medication administered or treatment is rendered;

13. Final diagnosis and discharge summary;

14. Date and time of discharge summary;

15. In case of death, cause and autopsy findings, if autopsy is performed, unless the death becomes subject to review by the coroner’s office, and;

16. Special examinations, if any, e.g., consultations, clinical laboratory, xray and other examinations.

B. Contingent upon the availability of pertinent information in the perinatal records of the mother, newborn records should include the following:

1. History of hereditary conditions in mother’s and/or father’s family;

2. First day of the last menstrual period (L.M.P.) and estimated day of confinement (E.D.C.);

3. Mother’s blood group and RH type evidence of sensitization and/or immunization (such as, administration of antiD hyperimmune globulin);

4. Serological test including dates performed for syphilis, HIV, Rubella, and Hepatitis B, results of any other tests performed during pregnancy (e.g., Group B Strep, Chlamydia, Gonorrhea, Herpes);

5. Number, duration and outcome of previous pregnancies, with dates;

6. Maternal disease (e.g., diabetes, hypertension, preeclampsia, infections);

7. Drugs taken during pregnancy, labor and delivery;

8. Results of measurements of fetal maturity and wellbeing (e.g., lung maturity and ultrasonography);

9. Duration of ruptured membranes and labor, including length of second stage;

10. Method of delivery, including indications for operative or instrumental interference;

11. Complications of labor and delivery (e.g., hemorrhage or evidence of fetal distress), including a representative strip of the fetal ECG if recorded;

12. Description of placenta at delivery, including number of umbilical vessels;

13. Estimated amount and description of amniotic fluid;

14. Apgar scores at one and five minutes of age. Description of resuscitations, if required, detailed description of abnormalities and problems occurring from birth until transfer to the special nursery or the referral facility;

15. Results and date specimen was collected for neonatal testing to detect inborn metabolic errors and hemoglobinopathies, including PKU, hypothyroidism and various other metabolic disorders. Exception: Parents may object because of religious grounds only, and in writing using a form promulgated by the Department; and

16. Results and dates of pulse oximetry screening and/or follow up of evaluation for critical congenital heart defects.

Exception: Parents may object only in writing to the screening for reason pertaining to religious beliefs.

C. When restraints are utilized, there must be an order to include length of time to be used and signed/authenticated by the legally authorized healthcare provider approving use of restraint or seclusion either at the time they are applied to a patient, or in case of emergency, within 24 hours after they have been applied. Each procedure manual shall contain information and instructions on the specific types of safety precautions that may or may not be used.

HISTORY: Amended by State Register Volume 38, Issue No. 6, Doc. No. 4430, eff June 27, 2014.

SECTION 1106 Orders for Medication and Treatment

All medical records shall contain the necessary consent forms for the treatment provided, along with orders for medication and treatment, signed/authenticated and dated by the prescriber or his designee. All orders, including verbal orders, shall be properly recorded in the medical record, dated and signed/authenticated by the prescriber within 30 days.

HISTORY: Amended by State Register Volume 38, Issue No. 6, Doc. No. 4430, eff June 27, 2014.

SECTION 1107 Storage

A. Provisions shall be made by the hospital for the storage of medical records in an environment which will prevent unauthorized access and deterioration. The records shall be treated as confidential and shall not be disposed of before 10 years. Records may be destroyed after 10 years provided that:

1. Records of minors must be retained until after the expiration of the period of election following achievement of majority as prescribed by statute; and

2. The hospital retains a register, either electronic or paper based.

B. Facilities that store records in a format other than paper, such as, but not limited to, microfilm, before 10 years have expired must include the entire record.

C. In the event of change of ownership, all medical records shall be transferred to the new owners.

D. Prior to the closing of a hospital for any reason, the facility shall arrange for preservation of records to ensure compliance with these regulations. The facility shall notify the Department, in writing, describing these arrangements.

HISTORY: Amended by State Register Volume 38, Issue No. 6, Doc. No. 4430, eff June 27, 2014.

SECTION 1108 Information to be Provided to Other Health Care Providers

In order to contribute to the continuity of quality of care, procedures must be established and implemented to provide discharge summaries and/or other appropriate information to health care providers to whom patients are discharged, transferred or referred.

HISTORY: Amended by State Register Volume 38, Issue No. 6, Doc. No. 4430, eff June 27, 2014.

SECTION 1109 Maintenance and Disposal

Records shall be maintained and disposed of as specified in Section 1107.

HISTORY: Added by State Register Volume 38, Issue No. 6, Doc. No. 4430, eff June 27, 2014.

SECTION 1110 Access to Medical Records

Only authorized personnel should have access to medical records and a hospital shall have policies and procedures to assure that a patient’s protected health information is private. The patient shall have access to his/her clinical records within a reasonable timeframe and a hospital shall have a process in place to facilitate that access if requested.


HISTORY: Added by State Register Volume 38, Issue No. 6, Doc. No. 4430, eff June 27, 2014.