reglab/statecodes huggingface dataset:
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3600 - MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 13B .3602 - RESPONSIBILITIES

Current through Register Vol. 39, No. 2, July 15, 2024
The governing body shall adopt written policies, rules, and
					 regulations that specify the officer or officers that shall:
(1) act for the chief executive officer in
				  his absence;
(2) manage the
				  facility consonant with its expressed aims and policies;
(3) attend meetings of the governing body and
				  appropriate meetings of the medical staff;
(4) implement policies adopted by the
				  governing body for the operation of the facility;
(5) organize the administrative functions of
				  the facility, delegate duties and establish formal means of accountability on
				  the part of subordinates;
(6)
				  establish such facility departments as are indicated, provide for departmental
				  and interdepartmental meetings and attend or be represented at such meetings,
				  and appoint hospital departmental representatives to medical staff committees
				  where appropriate or when requested to do so by the medical staff;
(7) appoint the heads of administrative
				  departments;
(8) report to the
				  governing body and to the medical staff on the overall activities of the
				  facility as well as on appropriate federal, State and local developments that
				  affect health care in the facility;
(9) review the annual audit of the financial
				  operations of the facility and acting upon recommendations therein;
(10) provide fiscal planning and financial
				  management of the facility including the provision of annual budgets and
				  periodic financial status reports to the governing board;
(11) develop in cooperation with the
				  departmental heads and other appropriate staff, an overall organizational plan
				  for the facility which will coordinate the functions, services and departments
				  of the facility, when possible; and
(12) require that the agreements with service
				  providers, such as laundry, laboratory and imaging, specifically indicate that
				  compliance will be maintained with applicable State rules as would apply to the
				  same services if provided directly by the facility.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3600 - MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 13B .3603 - PERSONNEL POLICIES AND PRACTICES

Current through Register Vol. 39, No. 2, July 15, 2024
The facility shall develop, establish and maintain
					 personnel policies and practices which support sound patient care. The policies
					 shall be in writing and made available to all employees, and they shall be
					 reviewed periodically but no less often than once every three years. The date
					 of the most recent review shall be indicated on the written policies. A
					 procedure shall be established for notifying employees of changes in the
					 established personnel policies.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3600 - MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 13B .3604 - JOB DESCRIPTIONS

Current through Register Vol. 39, No. 2, July 15, 2024
The facility shall develop and make available to the
					 employee a written job description for each type of job in the facility,
					 including the chief executive officer and heads of departments. Each job
					 description shall include a written description of the education, experience,
					 license, certification, or other qualifications required for the
					 position.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3600 - MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 13B .3605 - PERSONNEL RECORDS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The facility
				  shall maintain accurate and complete personnel records for each facility
				  employee during the term of employment and for two years thereafter. The chief
				  executive officer may designate an individual to carry out this
				  assignment.
(b) Personnel records
				  shall be maintained under such conditions as may be required by state or
				  federal law and shall contain at least the following:
(1) information regarding the employee's
				  education, training and experience and clinical competence, including, if
				  applicable, professional licensure status and license number, sufficient to
				  verify the employee's qualifications for the job for which he is employed. Such
				  information shall be kept current. Applicants for positions requiring a
				  licensed person shall be hired only after obtaining verification of their
				  licenses from the appropriate board;
(2) current information relative to periodic
				  work performance evaluations;
(3)
				  records of such pre-employment health examinations and of subsequent health
				  services rendered to the employees as are necessary to determine that all
				  facility employees are physically able to perform the essential duties of their
				  positions.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3600 - MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 13B .3606 - EDUCATION PROGRAMS

Current through Register Vol. 39, No. 2, July 15, 2024
The facility shall provide new employee orientation and
					 continuing education programs for all employees to maintain the skills
					 necessary for the performance of their duties and learn new developments in
					 health care. Records shall be maintained of all orientation and educational
					 programs, and of the participants.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3600 - MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 13B .3607 - PERSONNEL HEALTH REQUIREMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
Employees shall have pre-employment medical examinations
					 and interim examinations in accordance with medical criteria established by the
					 facility.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3600 - MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 13B .3608 - INSURANCE

Current through Register Vol. 39, No. 2, July 15, 2024
The governing board shall have in place an insurance
					 program which provides for the protection of the physical and financial
					 resources of the facility.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3600 - MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 13B .3609 - AUDIT OF FINANCIAL OPERATIONS

Current through Register Vol. 39, No. 2, July 15, 2024
An audit of the financial operations of the facility shall
					 be performed by a public accountant at least once a year.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3700 - MEDICAL STAFF › Section 13B .3701 - GENERAL PROVISIONS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The facility
				  shall have a self-governed medical staff that shall be accountable to the
				  governing body for the quality of care provided by individuals with medical
				  staff membership and clinical privileges to provide medical services in the
				  facility. Facility policy shall provide that individuals with clinical
				  privileges shall perform only services within the scope of individual
				  privileges granted.
(b) Minutes
				  required by the rules of this Section shall reflect all transactions,
				  conclusions, and recommendations of meetings. Minutes shall be prepared and
				  retained in accordance with a policy established by the facility and medical
				  staff, and available for inspection by members of the medical staff and
				  governing body, respectively, unless such minutes include confidential peer
				  review information that is not accessible to others in accordance with any law
				  protecting the confidentiality.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Readopted Eff. July 1,
					 2020.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3700 - MEDICAL STAFF › Section 13B .3702 - REPEALED - ESTABLISHMENT

Current through Register Vol. 39, No. 2, July 15, 2024
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Repealed Eff. July 1, 2020.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3700 - MEDICAL STAFF › Section 13B .3703 - APPOINTMENT

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The governing
				  body may grant, deny, renew, modify, suspend, or terminate medical staff
				  membership and clinical privileges after consideration of the recommendation
				  made by the medical staff in accordance with the bylaws established by the
				  medical staff and approved by the governing body for making such
				  recommendations, and the facility bylaws established by the governing body for
				  review and final determination of such recommendations.
(b) Review of an applicant for medical staff
				  membership and the granting of clinical privileges shall follow procedures set
				  forth in the bylaws, rules, and regulations of the medical staff. These
				  procedures shall require the following:
(1) a
				  signed application for medical staff membership, specifying date of birth, year
				  and school of graduation, date of licensure, statement of postgraduate or
				  special training and experience, and a statement of the scope of the clinical
				  privileges sought by the applicant;
(2) verification by the facility of the
				  applicant's qualifications as stated in the application, including any required
				  continuing education; and
(3)
				  written notice to the applicant from the governing body regarding appointment
				  or reappointment, which specifies the approval or denial of clinical privileges
				  and the scope of the privileges if granted.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3700 - MEDICAL STAFF › Section 13B .3704 - ESTABLISHMENT AND CATEGORIES OF MEDICAL STAFF MEMBERSHIP

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The
				  medical staff shall be established in accordance with the bylaws of the
				  facility and organized in accordance with the bylaws, rules, and regulations of
				  the medical staff. After considering the recommendations of the medical staff,
				  the governing body of the facility may, in accordance with
				  G.S.
				  131E-85, grant medical staff membership and
				  clinical privileges to qualified, licensed practitioners in accordance with
				  their training, experience, and demonstrated competence and judgment in
				  accordance with the medical staff bylaws, rules, and regulations.
(b) Every facility shall have an active
				  medical staff, as defined by the medical staff bylaws, rules, and regulations,
				  to deliver medical services within the facility and to administer medical staff
				  functions. The members of the active medical staff shall be eligible to vote at
				  medical staff meetings and to hold medical staff office positions as determined
				  by the medical staff bylaws, rules, and regulations and shall be responsible
				  for recommendations made to the governing body regarding the organization and
				  administration of the medical staff. Medical staff office positions shall be
				  determined in the medical staff bylaws, rules, and regulations.
(c) The active medical staff may establish
				  other categories for membership in the medical staff. These categories for
				  membership shall be identified and defined in the medical staff bylaws.
				  Examples of membership categories include:
(1) active medical staff;
(2) associate medical staff;
(3) courtesy medical staff;
(4) temporary medical staff;
(5) consulting medical staff;
(6) honorary medical staff; or
(7) other staff classifications.
The medical staff bylaws shall describe the authority,
					 duties, privileges, and voting rights for each membership category consistent
					 with applicable law, rules, and regulations and requirements of facility
					 accrediting bodies.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3700 - MEDICAL STAFF › Section 13B .3705 - MEDICAL STAFF BYLAWS, RULES, AND REGULATIONS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The
				  active medical staff shall develop and adopt, subject to the approval of the
				  governing body, a set of bylaws, rules, and regulations to establish a
				  framework for self-governance of medical staff activities and accountability to
				  the governing body.
(b) The medical
				  staff bylaws, rules, and regulations shall provide for the following:
(1) organizational structure;
(2) qualifications for medical staff
				  membership;
(3) procedures for
				  granting or renewing, denying, modifying, suspending, and revoking clinical
				  privileges;
(4) procedures for
				  disciplinary or corrective actions;
(5) procedures for fair hearing and appellate
				  review mechanisms for denying, modifying, suspending, and revoking clinical
				  privileges;
(6) composition,
				  functions and attendance of standing committees;
(7) policies for completion of medical
				  records;
(8) formal liaison between
				  the medical staff and the governing body;
(9) methods developed to formally verify that
				  each medical staff member on appointment or reappointment agrees to abide by
				  current medical staff bylaws, rules, and regulations, and the facility bylaws,
				  rules, policies, and regulations;
(10) procedures for participation in quality
				  assurance functions by medical staff members;
(11) the process for the selection and
				  election and removal of medical staff officers; and
(12) procedures for the proposal, adoption,
				  and amendment, and approval of medical staff bylaws, rules, and
				  regulations.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3700 - MEDICAL STAFF › Section 13B .3706 - ORGANIZATION AND RESPONSIBILITIES OF THE MEDICAL STAFF

Current through Register Vol. 39, No. 2, July 15, 2024
(a)
				  The medical staff shall be organized to accomplish its required functions as
				  established by the governing body and medical staff bylaws, rules, and
				  regulations and provide for the election or appointment of its own
				  officers.
(b) There shall be an
				  executive committee, or its equivalent, which represents the medical staff,
				  that has responsibility for the effectiveness of all medical activities of the
				  staff, and that acts for the medical staff.
(c) The following functions shall be
				  performed by the medical staff:
(1)
				  credentialing review;
(2) medical
				  records review;
(3) drug
				  utilization review;
(4) radiation
				  safety review;
(5) blood usage
				  review;
(6) bylaws
				  review;
(7) medical
				  review;
(8) peer review;
				  and
(9) recommendations for
				  discipline or corrective action of medical staff members.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3700 - MEDICAL STAFF › Section 13B .3707 - MEDICAL ORDERS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) No medication
				  or treatment shall be administered or discontinued except in response to the
				  order of a member of the medical staff in accordance with policies, rules, and
				  regulations established by the facility and medical staff and as provided in
				  Paragraph (f) of this Rule.
(b)
				  Such orders shall be dated and recorded directly in the patient medical record.
				  A method shall be established to safeguard against fraudulent
				  recordings.
(c) All orders for
				  medication or treatment shall be authenticated according to medical staff and
				  facility policies, rules, or regulations. The order shall be taken by personnel
				  qualified by medical staff bylaws, rules, and regulations, and shall include
				  the date, time, and name of persons who gave the order, and the full signature
				  of the person taking the order.
(d)
				  The names of drugs shall be recorded in full and not abbreviated except where
				  approved by the active medical staff.
(e) The active medical staff shall establish
				  a written policy in conjunction with the pharmacy committee or its equivalent
				  for all medications not specifically prescribed as to time or number of doses
				  to be automatically stopped after a reasonable time limit, but no more than 14
				  days. The prescriber shall be notified according to established policies and
				  procedures at least 24 hours before an order is automatically
				  stopped.
(f) For patients who are
				  under the continuing care of an out-of-state physician but are temporarily
				  located in North Carolina, a facility may process the out-of-state physician's
				  prescriptions or orders for diagnostic or therapeutic studies which maintain
				  and support the patient's continued program of care, where the authenticity and
				  currency of the prescriptions or orders can be verified by the physician who
				  prescribed or ordered the treatment requested by the patient, and where the
				  facility verifies that the out-of-state physician is licensed to prescribe or
				  order the treatment.
Authority
					 G.S.
					 131E-75;
					 131E-79;
Eff.
					 January 1, 1996;
Amended Eff. April 1, 2005; August 1,
					 1998;
Readopted Eff. July 1,
					 2020.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3700 - MEDICAL STAFF › Section 13B .3708 - MEDICAL STAFF RESPONSIBILITIES FOR QUALITY IMPROVEMENT REVIEW

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The medical staff shall have in effect a
				  system to review care provided at the facility by members of the medical staff,
				  to assess quality, to provide a process for quality improvement, and to monitor
				  the outcome of quality improvement activities.
(b) The medical staff shall establish
				  criteria for the evaluation of the quality of care.
(c) The facility shall have a written plan
				  that generates reports to permit identification of patient care problems and
				  that establishes a system to use this data to document and identify
				  interventions. The plan shall be approved by the medical staff, facility
				  administration, and the governing body.
(d) The medical staff shall establish a
				  policy to maintain a review process of the care provided by members of the
				  medical staff to all patients in every medical department of the facility. The
				  medical staff shall have a policy to schedule meetings to examine the review
				  process and results. The review process shall include both practitioners and
				  allied health professionals from the medical staff.
(e) Minutes shall be prepared for all
				  meetings reviewing quality improvement and shall reflect all of the
				  transactions, conclusions, and recommendations of the meeting.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22, 2017;
Amended Eff. July
					 1, 2020.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3800 - NURSING SERVICES › Section 13B .3801 - NURSE EXECUTIVE

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Whether the
				  facility utilizes a centralized or decentralized organizational structure, a
				  nurse executive shall be responsible for the coordination of nursing
				  organizational functions.
(b) A
				  nurse executive shall develop facility wide patient care programs, policies,
				  and procedures that describe how the nursing care needs of patients are
				  assessed, met, and evaluated.
(c)
				  The nurse executive shall develop and adopt, subject to the approval of the
				  facility, a set of administrative policies and procedures to establish a
				  framework to accomplish required functions as required in Paragraph (e) of this
				  Rule.
(d) There shall be scheduled
				  meetings every 60 days of the members of the nursing staff to evaluate the
				  quality and efficiency of nursing services. Minutes of these meetings shall be
				  maintained.
(e) The nurse executive
				  shall be responsible for:
(1) the development
				  of a written organizational plan which describes the levels of accountability
				  and responsibility within the nursing organization;
(2) planning for and the evaluation of the
				  delivery of nursing care system;
(3) establishment of a mechanism to validate
				  qualifications, knowledge, and skills of nursing personnel;
(4) provision of orientation and educational
				  opportunities related to expected nursing performance and maintenance of
				  records pertaining thereto;
(5)
				  implementation of a system for performance evaluation;
(6) provision of nursing care services in
				  conformance with
				  G.S.
				  90-171.20(7) and
				  G.S.
				  90-171.20(8);
(7) assignment of nursing staff to clinical
				  or managerial responsibilities based upon educational preparation, in
				  conformance with licensing laws and an assessment of current competence;
				  and
(8) staffing nursing units with
				  personnel in accordance with a written plan of care to meet the needs of the
				  patients.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3800 - NURSING SERVICES › Section 13B .3802 - NURSING STAFF

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Licensed nurses
				  and other nursing personnel shall be qualified by training, education,
				  experience and demonstrated abilities to provide nursing care within their
				  scope of practice.
(b) Staffing
				  schedules which reflect personnel assignment by date and service unit shall be
				  kept on file for at least three years by hospital management.
(c) The facility shall establish policies for
				  the provision of services for all contractual agreement personnel that include
				  at a minimum the following:
(1) verification
				  of licensure or certification by the appropriate occupational board;
(2) delivery and documentation of
				  care;
(3) participation on
				  interdisciplinary care planning activities; and
(4) supervision of contractual agreement
				  personnel.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3800 - NURSING SERVICES › Section 13B .3803 - NURSING POLICIES AND PROCEDURES

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Nursing
				  policies and procedures shall be available to the nursing staff in each nursing
				  care unit and service area and shall include the following:
(1) method of noting diagnostic and
				  therapeutic orders;
(2) method of
				  assigning nursing care of patients;
(3) infection control measures;
(4) patient safety measurers; and
(5) method of implementing orders for
				  medication or treatment.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3800 - NURSING SERVICES › Section 13B .3804 - PATIENT CARE

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Each patient's
				  need for nursing care related to his or her admission shall be determined by a
				  registered nurse. Patient needs shall be reassessed when warranted by the
				  patient's condition.
(b) Each
				  patient's nursing care shall be based upon assessed needs and shall be
				  coordinated with the therapies of other disciplines.
(c) The patient's medical record shall
				  include documentation of:
(1) the initial
				  assessment and reassessments of patient clinical status;
(2) patient care needs;
(3) interventions performed to meet the
				  patient's nursing care needs;
(4)
				  implementation of physician's orders;
(5) the nursing care provided; and
(6) the patient's response to, and the
				  outcomes of, the care provided.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3900 - MEDICAL RECORD SERVICES › Section 13B .3901 - ORGANIZATION

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The facility
				  shall establish a medical record service. It shall be directed, staffed and
				  equipped to accurately process, index, and file all medical records.
				  Orientation, on-the-job training and inservice programs for medical records
				  personnel shall be provided.
(b)
				  The medical record service shall be equipped to enable its personnel to
				  maintain medical records so that they are readily accessible and secure from
				  unauthorized use.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3900 - MEDICAL RECORD SERVICES › Section 13B .3902 - MANAGER

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The medical
				  records service shall be directed and supervised by a qualified medical records
				  manager. If the manager is not a registered record administrator or an
				  accredited records technician, the facility shall retain a person with those
				  qualifications on a part-time or consulting basis.
(b) The manager of the medical record service
				  shall advise, administer, supervise and perform work involved in the
				  development, analysis, maintenance and use of medical records and
				  reports.
(c) Where the manager is
				  employed on a part-time or consulting basis, he or she shall organize the
				  department, train the regular personnel and make periodic visits to the
				  facility. The manager shall evaluate the records and the operation of the
				  service and document the visits by written reports. A written contract
				  specifying his or her duties and responsibilities shall be kept on file and
				  made available for inspection by the Division's surveyor.
(d) The manager of the medical record service
				  shall maintain a system of identification and filing to facilitate the prompt
				  location of medical record of any patient.
(e) The manager of the medical records
				  service shall store medical records in such a manner as to provide protection
				  from loss, damage, and unauthorized access.
Authority
					 G.S.
					 131E-79;
RRC Objection due to
					 lack of Statutory Authority Eff. July 13, 1995;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3900 - MEDICAL RECORD SERVICES › Section 13B .3903 - PRESERVATION OF MEDICAL RECORDS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The manager
				  of the medical records service shall maintain medical records that were created
				  when the patient was an adult, whether original, computer media, or digital
				  archived for 11 years following the discharge of an adult patient.
(b) The manager of medical records shall
				  maintain medical records that were created when the patient was a minor,
				  whether original, computer media, or digital archived, until the patient's 30th
				  birthday. If a minor patient is readmitted as an adult, the manager of the
				  medical records shall maintain medical records according to Paragraph (a) of
				  this Rule.
(c) If a hospital
				  discontinues operation, its management shall make known to the Division where
				  its records are stored. Records shall be stored in a business offering
				  retrieval services for 11 years after the closure date or according to
				  Paragraph (b) of this Rule if the patient was a minor.
(d) The manager of medical records may
				  authorize the digital archiving of medical records. Digital archiving may be
				  done on or off the premises. If done off the premises, the facility shall
				  provide for the confidentiality and safekeeping of the records. The original of
				  digital archived medical records shall not be destroyed until the medical
				  records department has had an opportunity to review the digital record for
				  content.
(e) Nothing in this
				  Section shall be construed to prohibit the use of automation in the medical
				  records service, provided that all of the provisions in this Rule are met and
				  the information is readily available for use in patient care.
(f) Only personnel authorized by State laws
				  and the Health Insurance Portability and Accountability Act (HIPAA) found in
				  42 CFR
				  482, which is incorporated by reference
				  including subsequent amendments and editions, shall have access to medical
				  records. This regulation may be obtained free of charge at
https://www.govinfo.gov/help/cfr
.
				  Where the written authorization of a patient is required for the release or
				  disclosure of health information, the written authorization of the patient or
				  authorized representative shall be maintained in the original record as
				  authority for the release or disclosure.
(g) Medical records are the property of the
				  hospital, and shall remain the property of the hospital, except through a court
				  order. Copies shall be made available for authorized purposes such as insurance
				  claims and physician review.
Authority
					 G.S.
					 90-21.20B;
					 131E-79;
					 131E-97;
Eff.
					 January 1, 1996;
Amended Eff. July 1,
					 2009.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3900 - MEDICAL RECORD SERVICES › Section 13B .3904 - PATIENT ACCESS

Current through Register Vol. 39, No. 2, July 15, 2024
The manager of medical records shall provide patients or
					 patient designees, when requested, access to or a copy of their medical
					 records, or both. Upon the death of a patient, the executor of the decedent's
					 estate, or in the absence of an executor, the next of kin responsible for the
					 disposition of the remains, shall have access to all medical records of the
					 deceased patient. The patient or the patient's next of kin may be charged for
					 the cost of reproducing copies.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3900 - MEDICAL RECORD SERVICES › Section 13B .3905 - PATIENT MEDICAL RECORDS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Hospital
				  management shall maintain medical records for each patient treated or examined
				  in the facility.
(b) The medical
				  record or medical record system shall provide data for each episode of care and
				  treatment rendered by the facility.
(c) Where the medical record does not combine
				  all episodes of inpatient, outpatient and emergency care, the medical records
				  system shall:
(1) assemble, upon request of
				  the physician, any or all divergently located components of the medical record
				  when a patient is admitted to the facility or appears for outpatient or clinic
				  services; or
(2) require placing
				  copies of pertinent portions of each inpatient's medical record, such as the
				  discharge resume, the operative note and the pathology report, in the
				  outpatient or combined outpatient emergency unit record file as directed by the
				  medical staff.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3900 - MEDICAL RECORD SERVICES › Section 13B .3906 - CONTENTS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The medical
				  record shall contain sufficient information to justify the diagnosis, verify
				  the treatment and document the course of treatment and results
				  accurately.
(b) All in-patient
				  records shall include the following information:
(1) identification data (name, address, age,
				  sex) and, when the identification data is not obtainable, the reason for
				  such;
(2) date and time of
				  admission and discharge;
(3)
				  medical history:
(A) chief
				  complaint;
(B) details of the
				  present illness;
(C) relevant past,
				  social, and family histories; and
(D) reports of relevant physical
				  examinations;
(4)
				  diagnostic and therapeutic orders;
(5) reports of procedures, tests and their
				  results;
(6) provisional or
				  admitting diagnosis;
(7) evidence
				  of appropriate informed consent or a written statement explaining why consent
				  was not obtained;
(8) clinical
				  observations, including results of therapy;
(9) record of medication and treatment
				  administration;
(10) progress notes
				  of all disciplines;
(11)
				  conclusions at termination of hospitalization or evaluation and
				  treatment;
(12) all relevant
				  diagnosis established by the time of discharge;
(13) consultation reports;
(14) surgical record, including anesthesia
				  record, pre-operative diagnosis, surgeon's operative report and post-operative
				  orders and any instructions given to the patient or family; and
(15) autopsy findings, if
				  performed.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3900 - MEDICAL RECORD SERVICES › Section 13B .3907 - MEDICAL RECORDS REVIEW

Current through Register Vol. 39, No. 2, July 15, 2024
The medical staff shall review medical records periodically
					 for completeness and shall:
(1)
				  establish requirements regarding completion of medical records, including a
				  system for disciplinary actions for those who do not complete records in a
				  timely manner; and
(2) make
				  recommendations to the medical records department regarding clinical
				  information sufficient for medical care evaluation.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .4000 - OUTPATIENT SERVICES › Section 13B .4001 - ORGANIZATION

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The facility
				  shall establish and maintain outpatient care services in accordance with the
				  facility's written mission statement.
(b) The relationship of outpatient services
				  to other divisions within the facility, including channels of responsibility
				  and authority, shall be documented and made available for review by the
				  facility.
(c) The facility shall
				  vest the direction of outpatient services in one or more individuals whose
				  qualifications, authority and duties are defined in writing.
(d) The facility shall establish and maintain
				  procedures for the review and evaluation of outpatient services.
(e) Each medical staff member shall have
				  privileges delineated in accordance with criteria established by the medical
				  staff by-laws, rules, or regulations.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .4000 - OUTPATIENT SERVICES › Section 13B .4002 - STAFFING

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The director of
				  outpatient services shall require that ambulatory care services are staffed
				  with sufficient personnel in accordance with a written plan.
(b) The responsibility for the delivery of
				  outpatient services by the professional staff shall be defined and documented
				  by the director of ambulatory care services.
(c) The facility shall provide education
				  programs specifically related to outpatient care for the staff and document the
				  extent of participation in education and training programs.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .4000 - OUTPATIENT SERVICES › Section 13B .4003 - POLICIES AND PROCEDURES

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The provision
				  of outpatient services shall be guided by written policies and procedures which
				  shall be developed by the facility and approved by the medical staff. The
				  policies and procedures shall be reviewed by the medical staff at least every
				  three years.
(b) The policies shall
				  include the following:
(1) patient access to
				  outpatient services;
(2) the
				  process of obtaining informed consent;
(3) the location, storage and procurement of
				  medications, supplies and equipment; and
(4) the mechanism to be used to contact
				  patients for necessary follow-up.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .4000 - OUTPATIENT SERVICES › Section 13B .4004 - OUTPATIENT SURGICAL AND ANESTHESIA SERVICES

Current through Register Vol. 39, No. 2, July 15, 2024
(a) When
				  surgical or anesthesia services are provided in an outpatient setting, the
				  facility shall require that the medical staff approve all types of surgical
				  procedures to be offered. The facility shall maintain and make available a
				  current listing of approved outpatient procedures.
(b) The facility shall define the scope of
				  anesthesia services that may be provided, the locations where such anesthesia
				  services may be administered and who shall provide anesthesia
				  services.
(c) The facility shall
				  require that standards for informed consent, history and physical examination,
				  preoperative studies, administration of anesthesia, medical records and
				  discharge criteria meet the same standards of care as apply for inpatient
				  surgery unless otherwise specified by the medical staff.
(d) The facility shall provide for back-up
				  service by other departments in the case of emergencies or
				  complications.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .4000 - OUTPATIENT SERVICES › Section 13B .4005 - MEDICAL RECORDS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The manager of
				  outpatient services shall require that a record of outpatient care and services
				  for each patient is maintained either in the ambulatory care services or
				  medical records department.
(b) The
				  facility shall develop a system of identification and filing to prepare for
				  safe storage and prompt retrieval of records upon subsequent inpatient or
				  outpatient visits.
(c) The facility
				  shall establish medical records procedures which include provisions for
				  maintaining the confidentiality of patient information and for the release of
				  information to authorized individuals.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .4100 - EMERGENCY SERVICES › Section 13B .4101 - EMERGENCY RESPONSE CAPABILITY REQUIRED

Current through Register Vol. 39, No. 2, July 15, 2024
The medical staff of each facility shall require that
					 facility personnel are capable of initiating life-saving measures at a
					 first-aid level of response for any patient or person in need of such services.
					 This shall include:
(1) initiating
				  basic cardio-respiratory resuscitation according to American Red Cross or
				  American Heart Association standards;
(2) availability of first-line emergency
				  drugs as specified by the medical staff;
(3) availability of IV fluids and supplies
				  required to establish IV access; and
(4) establishing protocols or agreements for
				  the transfer of patients to a facility for a higher level of care when these
				  services are not available on site.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. July 22,
					 2017.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .4100 - EMERGENCY SERVICES › Section 13B .4102 - CLASSIFICATION OF OPTIONAL EMERGENCY SERVICES

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Any
				  facility providing emergency services shall classify its capability in
				  providing such services according to the following criteria:
(1) Level I:
(A) the facility shall have a comprehensive,
				  24-hour-per-day emergency service with at least one physician experienced in
				  emergency care on duty in the emergency care area;
(B) the facility shall have in-hospital
				  physician coverage by members of the medical staff or by senior-level residents
				  for at least medical, surgical, orthopedic, obstetric, gynecologic, pediatric
				  and anesthesia services;
(C)
				  services of other medical and surgical specialists shall be available;
				  and
(D) the facility shall provide
				  prompt access to labs, radiology, operating suites, critical care and obstetric
				  units and other services as defined by the governing body.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .4100 - EMERGENCY SERVICES › Section 13B .4103 - PROVISION OF EMERGENCY SERVICES

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Any facility
				  providing emergency services shall establish and maintain policies requiring
				  medical screening, treatment and transfer services for any individual who
				  presents to the facility emergency department and on whose behalf treatment is
				  requested regardless of that person's ability to pay for medical services and
				  without delay to inquire about the individual's method of payment.
(b) Any facility providing emergency services
				  under the rules of this Section shall install, operate, and maintain, on a
				  24-hour per day basis, an emergency two-way radio capable of accessing the
				  North Carolina Voice Interoperability Plan for Emergency Responders (VIPER)
				  radio network for voice communication with EMS providers transporting patients
				  to the facility or provide on-line medical direction for EMS
				  personnel.
(c) All communication
				  equipment shall be in compliance with the rules set forth in
				  10A NCAC
				  13P, Emergency Medical Services and Trauma
				  Rules.
Authority
					 G.S.
					 131E-79;
Eff. January 1,
					 1996.
North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .4100 - EMERGENCY SERVICES › Section 13B .4104 - MEDICAL DIRECTOR

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The governing
				  body shall establish the qualifications, duties, and authority of the director
				  of emergency services. Appointments shall be recommended by the medical staff
				  and approved by the governing body.
(b) The medical staff credentials committee
				  shall approve the mechanism for emergency privileges for physicians employed
				  for brief periods of time such as evenings, weekends, or holidays.
(c) Level I and II emergency services shall
				  be directed and supervised by a physician.
(d) Level III services shall be directed and
				  supervised by a physician.
Authority
					 G.S.
					 131E-79;
RRC objection due to
					 lack of statutory authority Eff. July 13, 1995;
Eff. January 1,
					 1996.