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016.06.41-202.000. Medical Records Rehabilitative Hospitals are Required to Keep.

AR ADC 016.06.41-202.000Arkansas Administrative Code

West's Arkansas Administrative Code
Title 016. Department of Human Services
Division 06. Division of Medical Services
Rule 41. Rehabilitative Hospital Provider Manual (Refs & Annos)
Section 200.000. Rehabilitative Hospital General Information.
Ark. Admin. Code 016.06.41-202.000
016.06.41-202.000. Medical Records Rehabilitative Hospitals are Required to Keep.
Currentness
Rehabilitative hospitals are required to keep the following records and, upon request, furnish the records to authorized representatives of the Arkansas Division of Medical Services, the State Medicaid Fraud Control Unit and representatives of the Department of Health and Human Services and the Centers for Medicare and Medicaid Services:
A. History and physical examination at time of admission
B. Chief complaint at time of admission, including admitting diagnosis
C. Tests and results during hospitalization
D. Progress notes by attending physician
E. Signature or initials of patient's physician after each visit
F. Physician's orders
G. Nurses' notes
H. Operative report (if applicable)
I. Tissue report (if applicable)
J. Discharge orders
K. Pharmacy and drug records
L. Discharge summary
M. All Utilization Review (UR) documentation made by the UR coordinator and/or physician advisor during patient's hospitalization.

Credits

Eff. Oct. 13, 2003.
<Editor’s Note: Nonfunctioning links so in original.>
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 016.06.41-202.000, AR ADC 016.06.41-202.000
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