Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-11 - Medical record services

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The EH shall have medical record services that ensure a
				medical record is maintained for every patient evaluated or treated in the
				facility. Medical record services shall be appropriate to the scope and
				complexity of the services performed and shall ensure prompt completion,
				filing, and retrieval of records. In general, services such as transcription,
				computer indexing and coding, and electronic storage may be performed off-site
				as a contracted service as long as the medical record remains under the control
				of the EH. The EH shall ensure that medical records maintained by a contracted
				service remain confidential and can be immediately accessed by EH
				staff.
(b)
Reports to
				agencies and the Department.
The EH shall comply with all requirements
				specified in OAC
				310:667-19-2(a)
				regarding the reports made to agencies and the Department.
(c)
Content.
The medical record
				shall contain information to justify patient admission and treatment, support
				the diagnosis, and describe the patient's progress and response to treatment
				and services received. All entries shall be legible and complete, and shall be
				authenticated and dated promptly by the person, identified by name and
				discipline, who is responsible for ordering, providing or evaluating the
				service furnished.
(1) The author of each
				entry shall be identified and shall authenticate their entry. Authentication
				may include written signatures or computerized or electronic entries. If
				computerized or electronic authentications are used, the EH shall comply with
				all requirements specified at OAC
				310:667-19-10(e).
				Telephone or verbal orders shall be authenticated by the physician or
				practitioner giving the order or meet the requirements at OAC
				310:667-19-2(c)(4).
				The person taking the telephone or verbal order shall read the order back to
				the physician or practitioner to ensure it was correctly understood and verify
				on the order the fact that the order was read back. Each facility, within its
				own procedures and protocols, shall establish a verification process to be
				placed on orders to demonstrate that the order was read back to the
				physician.Reports of history and physical examinations and discharge summaries
				shall be authenticated by the authorized physician or practitioner who
				performed the examination or produced the summary or meet the requirements at
				OAC
				310:667-19-10(e)
				if authenticated by another physician or practitioner. Signature stamps may be
				used to authenticate entries in the medical record provided the requirements at
				OAC
				310:667-19-10(d)
				are met.
(2) All inpatient records
				shall document the following as appropriate:
(A) Patient identifying information including
				individuals to be contacted in case of an emergency.
(B) Evidence of a physical examination,
				including a health history, performed not more than thirty (30) days prior to
				admission or within forty-eight (48) hours after admission. The history and
				physical examination shall be completed, signed and placed in the record within
				48 hours of admission.
(C)
				Admitting diagnosis.
(D) Results of
				all consultative evaluations of the patient and appropriate findings by
				clinical and other staff involved in the care of the patient.
(E) Documentation of complications, hospital
				acquired infections, and unfavorable reactions to any drug or
				biological.
(F) Properly executed
				informed consent forms for procedures and treatments performed. The medical and
				professional staff shall establish which procedures or treatments require
				informed consent consistent with Federal and State law.
(G) All physicians' and practitioners'
				orders, nursing notes, reports of treatment, medication records, diagnostic
				reports, vital signs and other information necessary to monitor the patient's
				condition.
(H) Discharge summary
				with outcome of hospitalization, disposition of case, medications at the time
				of discharge, and provisions for follow-up care.
(I) Reports. All reports and records shall be
				completed and filed within a period consistent with good medical practice and
				not longer than thirty (30) days following discharge.
(J) Final diagnosis.