Alabama Administrative Code › Title 420 - ALABAMA STATE BOARD OF HEALTH › Chapter 420-5-18 - SLEEP DISORDERS FACILITIES › Section 420-5-18-.06 - Medical Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
Patient Charts
. Charts should be well-organized and
			 the information in them easily accessible. Materials such as questionnaires,
			 sleep and temperature logs, and psychological tests should be made part of the
			 patient's chart.
(2)
Narrative Entries
. Narrative entries must be included
			 in the patient chart to document all patient contacts, to review results, and
			 to record diagnosis, treatment plan, and mode of implementation. Patient intake
			 information must be included in each chart and include appropriate histories
			 and physicals.
(3)
Diagnostic Information
. All diagnostic information,
			 regardless of its state of development during the course of the work-up, should
			 be in written form. A consulting cardiologist, for example, should be required
			 to submit a written report. All clinical information relative to a patient's
			 sleep study and treatment shall be documented in a single patient chart and
			 stored in the sleep disorder facility until the file becomes inactive. Active
			 patient charts should be readily available at all times.
(4)
Summary
. A
			 written summary of each case must be placed in the chart by the responsible
			 physician at the time that treatment recommendations or procedures are
			 undertaken. Summaries should include not only a description of the procedure
			 performed, but also a soundly reasoned analysis of the clinical significance of
			 these procedures and their implications for the management of the
			 patient.
(5)
Statement
			 of Follow-up Plan
. The patient's record must contain a description
			 of follow-up procedures, whether or not the treatment is executed by the
			 facility. If the facility is not providing the treatment, the record must be
			 explicit as to how contact will be maintained with the patient or referring
			 source. In order to ensure that the highest quality care is being provided, a
			 formal, efficient, and effective vehicle must be used by staff physicians to
			 convey the results of the evaluation and treatment options to the patient and
			 the physician or others who referred the patient to the facility. Consequently,
			 each patient's chart should have a copy of the correspondence which states the
			 diagnostic assessment of the patient and a recommended treatment plan if the
			 disorder has a known treatment. This communication should be sent with a
			 reasonable time after the completion of the evaluation.
(6)
Final Diagnosis
.
			 All final Diagnoses must be made using ASDA nosology as established in a
			 current
International Classification of Sleep Disorders Diagnostic
			 and Coding Manual
.
(7)
Storage and Safety
. Provisions shall be made for the
			 safe storage and confidentiality of records.
(8)
Retention of
			 Records
. Medical records must be retained in their original or
			 legally reproduced form for a period of at least five years.
(9)
Proposed Plan for Disposition
			 for Medical Records
. When a sleep disorders facility ceases to
			 operate, either voluntarily or by revocation of its license, the governing body
			 (licensee) at or prior to such action shall develop a proposed plan for the
			 disposition of its medical records. Such plan shall be submitted for review and
			 approval to the Division of Licensure and Certification and shall contain
			 provision for the proper storage, safeguarding and confidentiality, transfer
			 and/or disposal of patient medical records.
Author:
Statutory Authority:
Code of Ala.
				  1975
, Title 22, Chapter 21.