Louisiana Administrative Code › Title 48 - PUBLIC HEALTH-GENERAL › Part I - General Administration › Subpart 3 - Licensing and Certification › Chapter 93 - Hospitals › Subchapter H - Medical Record Services › Section I-9387 - Organization and Staffing

Current through Register Vol. 50, No. 6, June 20, 2024
A. There
					 shall be a medical records department that has administrative responsibility
					 for maintaining medical records for every person evaluated or treated as an
					 inpatient, outpatient or emergency patient. Medical records for patients at
					 off-site campuses shall be integrated into the unified records system of the
					 provider.
B. Medical records shall
					 be under the supervision of a medical records practitioner (i.e., registered
					 record administrator or accredited record technician) on either a full-time,
					 part-time or consulting basis.
C.
					 Medical records shall be legibly and accurately written in ink, dated and
					 signed by the recording person or, if a computerized medical records system is
					 used, authenticated, complete, properly filed and retained, and
					 accessible.
D. If a facsimile
					 communications system (fax) is used, the hospital shall take precautions when
					 thermal paper is used to ensure that a legible copy is retained as long as the
					 medical record is retained.
E.
					 Written orders signed by a member of the medical staff shall be required for
					 all medications and treatments administered to patients. There shall be a
					 reliable method for personal identification of each patient. The medical staff
					 bylaws shall include specifications for orders for the care or treatment of
					 patients which are given to the hospital verbally or transmitted to the
					 hospital electronically, whether by telephone, facsimile transmission or
					 otherwise. The bylaws may grant the medical staff up to ten days following the
					 date an order is transmitted verbally or electronically to provide the
					 signature or countersignature for such order.
F. If rubber stamp signatures are authorized
					 for physician use, the administrative office shall have on file a signed
					 statement from the medical staff member whose stamp is involved that ensures
					 that he/she is the only one who has the stamp and uses it. The delegation of
					 their use by others is prohibited.
G. If electronic signatures are used, the
					 hospital shall develop a procedure to assure the confidentiality of each
					 electronic signature and to prohibit the improper or unauthorized use of any
					 computer generated signature.
H.
					 There shall be adequate medical record personnel to ensure prompt completion,
					 filing and retrieval of records.
I.
					 The hospital shall have a system of coding and indexing medical records. The
					 system shall allow for timely retrieval by diagnosis and procedure, in order to
					 support quality assessment and improvement evaluations.
J. The hospital shall ensure that all medical
					 records are completed within 30 days following discharge.
K. A patient or his/her personal
					 representative shall be given reasonable access to the information contained in
					 his/her hospital record. The hospital shall, upon request in writing signed and
					 dated by either the patient or personal representative initiating the request,
					 furnish a copy of the hospital record as soon as practicable, not to exceed 15
					 days following the receipt of the request and written authorization and upon
					 payment of the reasonable cost of reproduction in accordance with Louisiana
					 R.S.
					 40:1299.96. However, the hospital may deny
					 the patient access if a licensed health care professional has determined, in
					 the exercise of professional judgment, that the access requested is reasonably
					 likely to endanger the life or physical safety of the patient or another
					 person.
L. Upon request of a
					 competent adult victim of a sexually oriented criminal offense as defined in
					 R.S.
					 15:622, or current law, the hospital that
					 performed the forensic medical exam shall provide a reproduction of any written
					 documentation which is in the possession of the hospital resulting from the
					 forensic medical exam of the victim.
1. The
					 documentation shall be provided to the victim no later than 14 days after the
					 hospital receives the request or the hospital completes the documentation,
					 whichever is later.
2. The
					 reproduction of written documentation provided for in this Subsection shall be
					 made available at no cost to the victim and may only be released at the
					 direction of the victim who is a competent adult. This release does not
					 invalidate the victim's reasonable expectation of privacy nor does the record
					 become a public record after the release to the victim.