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007.05.10-14. Health Information Services.

AR ADC 007.05.10-14Arkansas Administrative CodeEffective: June 20, 2022

West's Arkansas Administrative Code
Title 007. Department of Health
Division 05. Health Facility Services
Rule 10. Rules for Critical Access Hospitals in Arkansas (Refs & Annos)
Effective: June 20, 2022
Ark. Admin. Code 007.05.10-14
007.05.10-14. Health Information Services.
A. General Requirements.
1. A medical record shall be maintained for each patient admitted for care in the hospital.
2. The original or a copy of the original (when the original is not available) of all reports shall be filed in the medical record.
3. The record shall be permanent and shall be either typewritten or legibly written in blue or black ink.
4. All typewritten reports shall include the date of dictation and the date of transcription.
5. All dictated records shall be transcribed within 48 hours.
6. Errors shall be corrected by drawing a single line through the incorrect data, labeling it as “Error,” initialing, and dating the entry.
7. Additional patient records room requirements are provided in Section 61, Physical Facilities, and Health Information Unit.
8. Disease, operation, and physicians' indices shall be maintained (manual, abstract, or computer). Records shall be indexed within one month following discharge. Indices maintained on computer shall be retrievable at any time for research or quality assurance/performance improvement monitoring.
9. Records of discharged patients shall be coded in accordance to accepted coding practices. Records shall be coded within one month of the patient's dictated discharge summary.
10. Relevant educational programs shall be conducted at regularly scheduled intervals with no less than 12 per year. There shall be written documentation with employee signatures, program title/subject, presenter, date, and outlines or narrative of presented program.
11. A Master Patient Index shall be maintained by the Health Information Services. Index information shall include at least the full name, address, birth date, and the medical record number of the patient. The index may be maintained manually or on computer and shall contain the dates of all patient visits to the facility. If the Index is maintained on computer, there shall be a policy and procedure on permanent maintenance.
12. Birth certificates shall be completed according to the current rules and regulations of Vital Records, Arkansas Department of Health.
13. A unit record system shall be maintained. A unit record is defined as all inpatient and outpatient visits for each patient being filed together in one unit.
14. A policy and procedure manual for the Health Information Management Department shall be developed. The manual shall have evidence of ongoing review and/or revision. The first page of each manual shall have the annual review date, signature of the department supervisor and/or person(s) conducting the review.
15. A qualified individual shall be employed to direct the hospital's Health Information Department. If a Registered Health Information Administrator (RHIA) or a Registered Health Information Technician (RHIT) is not employed as Director on a full-time basis by the hospital, a consultant shall make periodic visits to evaluate functions of the Department and train personnel.
16. All patient records, whether stored within the Health Information Management Department or other areas, either within the facility or away from the facility, shall be protected from destruction by fire, water, vermin, dust, etc.
17. Medical records shall be considered confidential. Only authorized personnel shall have access to the medical records. All medical records (including those filed outside the department) shall be secured at all times. If authorized personnel are not available, the department shall be locked. Records shall be available to authorized personnel from the Arkansas Department of Health.
18. Release of medical information shall be restricted by the facility's policies and procedures.
19. All medical records shall be retained in either the original, microfilm or other acceptable methods for 10 years after the last discharge. After 10 years a medical record may be destroyed provided the facility permanently maintains the information contained in the Master Patient Index. Complete medical records of minors shall be retained for a period of two years after the age of majority.
20. Procedures shall be developed for the retention and accessibility of the patients' medical records if the hospital or other facility closes. The medical records shall be stored for the required retention period and shall be accessible for patient use.
21. All entries into the medical record shall be legible. There shall be no erasures or obliterations of the original information contained in a medical record.
22. Medical records shall be complete and contain all required signed documentation (including physician reports) no later than 30 days following the patient's discharge date.
23. Patient records shall be destroyed by burning or shredding. Patient records shall not be disposed of in landfills or other refuse collection sites.
24. A QA/PI program shall be continuous and specific to the services.
25. In the event of a physician's death or permanent incapacitation, incomplete medical records shall be reviewed in a manner approved by the Medical Staff. Approval to file incomplete medical records shall be obtained in a manner approved by the Medical Staff and a statement explaining the circumstances be placed in each record.
B. Authentication of Medical Record Entries.
1. Each entry into the medical record shall be authenticated by the individual who is the source of the information. Entries shall include all documents, observations, notes, and any other information included in the record.
2. Signatures shall be at least, the first initial, last name and title. Computerized signatures may be either by code, number, initials, or the method developed by the facility.
3. The hospital's Medical Staff and Governing Body shall adopt a policy regarding dictation that permits authentication by electronic or computer generated signature. The policy shall identify those categories of the staff within the hospital that are authorized to authenticate patient records using electronic or computer generated signatures.
4. At a minimum, the policy shall include adequate safeguards to ensure confidentiality.
a. Each user shall be assigned a unique identifier which is generated through a confidential code.
b. The policy shall include penalties for inappropriate use of the identifier.
c. The user shall certify, in writing, that he or she is the only person authorized to use the signature code.
d. The hospital shall periodically monitor the use of identifiers; the process by which the monitoring shall be conducted shall be described in the policy.
5. The system shall make an opportunity available to the user to verify that the document is accurate and the signature has been properly recorded.
6. Each report generated by a user shall be separately authenticated.
7. A user may terminate authorization for use of electronic or computer generated signature upon written notice to the Director of Health Information Services.
8. Rubber stamp signatures shall be acceptable if a letter from the physician is on file explaining that the physician shall be the only person using the stamp and the stamp shall remain in his/her possession at all times. The signature stamp shall be the full legal name of the physician with his/her professional title.
9. Transcribed reports dictated by other than the attending physician shall be signed by the credentialed individual dictating the report and the attending physician. Dictation of reports by other than the attending physician is limited to history, physical, discharge summary, operative reports and progress notes. Reports dictated by resident physicians for training purposes require only the signature of the attending physician.
C. Electronic Health Information
1. Policies and procedures governing electronic health information within the organization and with external entities shall be adopted by the Governing Body.
2. The policies and procedures shall provide for the use, exchange, security and privacy of electronic health information. The policies and procedures shall provide for standardized and authorized availability of electronic health information for patient care, administrative purposes and research. The policies and procedures will be in compliance with current guidelines and standards as established in federal and state status.
D. Record Content.
1. Identification data shall include at least the following:
a. Patient's full name -- maiden name if applicable;
b. Patient's address, telephone number, and occupation;
c. Date of birth;
d. Age;
e. Sex;
f. Marital status (M.S.D.W.);
g. Dates and times of admission and discharge;
h. Full name of physician;
I. [FN1] Name and address of nearest relative or person or agency responsible for patient and occupation of responsible party;
j. Name, address, and telephone number of person(s) to notify in case of emergency; and,
k. Medical record number.
2. A general consent for medical treatment and care. This shall be signed by the patient or guardian. Written or verbal consent shall not release the hospital or its personnel from upholding the rights of its patients including but not limited to the right to privacy, dignity, security, confidentiality, and freedom from abuse or neglect.
3. A consent for a do-not-resuscitate order or otherwise withholding or withdrawing treatment of a minor.
a. The consent shall:
1. Include the written or verbal consent of at least one parent or guardian of the minor;
2. Include the signature of two (2) witnesses attesting the consent was given by at least one parent or guardian when the consent was given verbally
3. Be documented in the minor's medical record, specifying the parent or guardian who gave consent, the witnesses present, and the date and time the consent was obtained.
b. The consent does not apply if the minor is married, pregnant, emancipated, or incarcerated in the Division of Corrections, or the Division of Community Corrections, or in the custody of the Department of Human Service.
c. Does not apply if a reasonable diligent effort of at least seventy-two (72) without success has been made to contact and inform each know parent or guardian of intent to issue a do-not-resuscitate order or otherwise withhold or withdraw treatment so as to allow the natural death of a minor.
d. The parent or guardian may revoke the consent verbally or in writing.
4. Clinical reports shall include the following and shall comply with listed requirements:
a. A History and Physical Examination (HPE) shall be in the patient's medical record within 48 hours of the patient's admission to the facility. The HPE must be authenticated by the attending or treating physician and shall contain the following:
1) Family (medical) history and review of systems -- if noncontributory, the record shall reflect such;
2) Past medical history;
3) Chief complaint(s) -- a brief statement of nature and duration of the symptoms that caused the patient to seek medical attention as stated in the patient's own words;
4) Present illness with dates or approximate dates of onset;
5) Physical examination;
6) Provisional or admitting diagnosis(es); and
7) History and physical examinations may be completed up to 30 days prior to admission if the examination is updated at the time of admission. The updated HPE must be authenticated by the attending or treating physician.
b. Progress notes shall be recorded, dated and signed. The frequency of the physician's progress notes shall be determined by the patient's condition. Dictated progress notes are acceptable and shall be placed in the patient's medical record within 48 hours.
c. Orders including verbal orders shall be authenticated with a legible and dated signature in a timely manner as defined by Medical Staff By-Laws.
d. A discharge summary shall recapitulate the significant findings and events of the patient's hospitalization and his/her condition on discharge. The discharge summary must be authenticated by the attending or treating physician within 30 days of the patient's discharge. The final diagnosis shall be stated in the discharge summary.
e. Autopsy findings shall be documented in complete protocol within 60 days and the provisional anatomical diagnosis shall be recorded within 72 hours. A signed authorization for autopsy shall be obtained from the next of kin and documented in the medical record before an autopsy is performed.
f. Original, signed diagnostic reports (laboratory, X-rays, CATs, SCANs, EKGs, fetal monitoring, EEGs) shall be filed in the patient's medical record. Physicians' orders shall accompany all treatment procedures. Fetal monitor and EEG tracings may be filed separately from the medical record if accessible when needed.
g. Reports of ancillary services (Dietary, Physical Therapy, Respiratory Care, Social Services, etc.) shall be included in the patient's medical record.
h. Reports of Medical Consultation, if ordered by the attending physician, shall be included in the patient's medical record within time frames established by the Medical Staff.
E. Records of Complementary Departments. In addition to the general record content requirements stated above, parts F., G. and H. are required, as applicable.
F. Surgery Records.
1. A specific consent for surgery shall be documented prior to the surgery/procedure to be performed, except in cases of emergency, and shall include the date, time and signatures of the patient and witness. Consent shall be obtained by the surgeon and documented in the patient's medical record. (Abbreviations are not acceptable.)
2. A History and Physical Examination (HPE) on admission containing medical history and physical findings shall be documented in the patient's medical record prior to surgery. In cases of emergency surgery, an abbreviated physical examination, and a brief description of why the surgery is necessary shall be included in the HPE. (See Section 14, Health Information Services, Record Content.) The HPE must be authenticated by the attending or treating physician or surgeon.
3. An anesthesia report, including preoperative evaluation and postoperative assessment, shall be documented by the Anesthesiologist and/or Certified Registered Nurse Anesthetist (CRNA). The pre-evaluation and post assessment shall be dated and timed.
a. Preoperative anesthesia evaluation shall be completed prior to the patient's surgery.
b. Report of Anesthesia. A CRNA who has not been granted authority by a facility, as a DEA registrant, to order the administration of controlled substances shall give all orders as verbal orders from the supervising physician, dentist, or other person lawfully entitled to order an anesthetic.
c. Post anesthesia assessment shall be documented in the medical record prior to the patient's discharge, not to exceed 48 hours after the patient's surgery. If the patient is in need of continued observation, the anesthetist shall be readily available. Discharge criteria shall be established and approved by the Medical Staff and Governing Body. If the patient meets the discharge criteria within a three-hour period postoperatively, a post anesthesia assessment is not required.
4. An individualized operative report shall be written or dictated by the physician or surgeon immediately following surgery and shall be signed within 72 hours. The report shall describe (in detail) techniques, findings, pre and postoperative diagnosis, and tissues removed.
5. A signed pathological report shall be maintained in the medical record of all tissue surgically removed. A specific list of tissues exempt from pathological examination shall be developed by the Medical Staff.
G. Obstetrical Records.
1. A pertinent prenatal record shall be updated upon admission, or history and physical examination signed by the physician shall be available upon the patient's admission and be maintained in the patient's medical record.
2. A record of labor and delivery, authenticated by the physician, shall be maintained for every Obstetrical patient.
3. Documentation of the patient's recovery from delivery shall be maintained.
4. Nurses' postpartum record, graphics and nurses' notes shall be maintained.
H. Newborn Records.
1. A newborn history and physical examination shall be completed by the physician within 24 hours of birth. The following additional data shall be required:
a. History of the newborn delivery (sex, date of birth, type of delivery, and anesthesia given the mother during labor and delivery); and
b. Physical examination (weight, date, time of birth, and condition of infant after birth).
2. There shall be a consent for circumcision (if applicable).
3. A procedure note for circumcision shall be documented by the physician.
4. A discharge note or summary describing the condition of the newborn at discharge and follow-up instructions given to the mother must be prepared and included in the medical record. The discharge note or summary must be authenticated by the attending or treating physician.
5. Hospitals shall comply with State Law and Health Department requirements for newborn testing. See Rules Pertaining to Testing of Newborn Infants and Ark. Code Ann. § 20-15-301 et seq.
6. Birth certificates shall be completed on all infants born in the hospital, or admitted as a result of birth in accordance with the requirements of Vital Records, Arkansas Department of Health.

Credits

Amended Jan. 1, 2016; Feb. 5, 2021; June 20, 2022.
[FN1]
So in original.
<Statutory authority: Promulgated under the Authority of Ark. Code Ann. § 20-7-123, 20-9-201 et seq.>
Current with amendments received through May 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 007.05.10-14, AR ADC 007.05.10-14
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