Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 300 - SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE › Subpart I - RESIDENT AND FACILITY RECORDS › Section 300.1810 - Resident Record Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Each facility shall have a medical record system that retrieves information
				regarding individual residents.
b)
				The facility shall keep an active medical record for each resident. This
				resident record shall be kept current, complete, legible and available at all
				times to those personnel authorized by the facility's policies, and to the
				Department's representatives.
c)
				Record entries shall meet the following requirements:
1) Record entries shall be made by the person
				providing or supervising the service or observing the occurrence that is being
				recorded.
2) All entries into the
				medical record shall be authenticated by the individual who made or authored
				the entry. "Authentication", for purposes of this Section, means identification
				of the author of a medical record entry by that author and confirmation that
				the contents are what the author intended.
3) Medical record entries shall include all
				notes, orders or observations made by direct resident care providers and any
				other individuals authorized to make such entries in the medical record, and
				written interpretive reports of diagnostic tests or specific treatments
				including, but not limited to, radiologic or laboratory reports and other
				similar reports.
4) Authentication
				shall include the initials of the signer's credentials. If the electronic
				signature system will not allow for the credential initials, the facility shall
				have a means of identifying the signer's credentials.
5) Electronic Medical Records Policy. The
				facility shall have a written policy on electronic medical records. The policy
				shall address persons authorized to make entries, confidentiality, monitoring
				of record entries, and preservation of information.
A) Authorized Users. The facility shall
				develop a policy to assure that only authorized users make entries into medical
				records and that users identify the date and author of every entry in the
				medical records. The policy should allow written signatures, written initials
				supported by a signature log, or electronic signatures with assigned
				identifiers, as authentication by the author that the entry made is complete,
				accurate and final.
B)
				Confidentiality. The facility policy shall include adequate safeguards to
				ensure confidentiality of patient medical records, including procedures to
				limit access to authorized users. The authorized user must certify in writing
				that he or she is the only person with authorized user access to the identifier
				and that the identifier will not be shared or used by any other person. A
				surveyor or inspector in the performance of a State-required inspection may
				have access to electronic medical records, using the identifier and under the
				supervision of an authorized user from the facility. A surveyor or inspector
				may have access to the same electronic information normally found in written
				patient records. Additional summary reports, analyses, or cumulative statistics
				available through computerized records are the internal operational reports of
				the facility's Quality Assurance Committee.
C) Monitoring. The facility shall develop a
				policy to periodically monitor the use of identifiers and take corrective
				action as needed. The facility shall maintain a master list of authorized users
				past and present and maintain a computerized log of all entries. The logs shall
				include the date and time of access and the user ID under which access
				occurred.
D) Preservation. The
				facility shall develop a plan to ensure access to medical records over the
				entire record retention period for that particular piece of
				information.
6) A user
				may terminate authorization for use of electronic or computer-generated
				signature upon written notice to the individual responsible for medical records
				or other person designated by the facility's policy.
7) Each report generated by a user must be
				separately authenticated.