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20 CAR § 41-113. Health Information Services
20 CAR § 41-113. Health Information Services.
(a) General requirements.
(1) A medical record shall be maintained for each patient admitted for care in the hospital.
(2) The original, or a copy of the original when the original is not available, of all reports shall be filed in the medical record.
(3) The record shall be:
(A) Permanent; and
(B) Either:
(i) Typewritten; or
(ii) Legibly written in blue or black ink.
(4) All typewritten reports shall include the:
(A) Date of dictation; and
(B) Date of transcription.
(5) All dictated records shall be transcribed within forty-eight (48) hours.
(6) Errors shall be corrected by:
(A) Drawing a single line through the incorrect data;
(B) Labeling it as “Error”; and
(C) Initialing and dating the entry.
(7) Additional patient records room requirements are provided in 20 CAR § 41-164, physical facilities — health information unit.
(8)(A) Disease, operation, and physicians’ indices shall be maintained (manual, abstract, or computer).
(B) Records shall be indexed within one (1) month following discharge.
(C) Indices maintained on computer shall be retrievable at any time for research or quality assurance/performance improvement monitoring.
(9)(A) Records of discharged patients shall be coded in accordance to accepted coding practices.
(B) Records shall be coded within one (1) month of the patient’s dictated discharge summary.
(10)(A) Relevant educational programs shall be conducted at regularly scheduled intervals with no less than twelve (12) per year.
(B) There shall be written documentation with:
(i) Employee signatures;
(ii) Program title/subject;
(iii) Presenter;
(iv) Date; and
(v) Outlines or narrative of presented program.
(11)(A) A master patient index shall be maintained by the Health Information Services.
(B) Index information shall include at least the full name, address, birth date, and the medical record number of the patient.
(C) The index:
(i) May be maintained manually or on computer; and
(ii) Shall contain the dates of all patient visits to the facility.
(D) If the index is maintained on computer, there shall be a policy and procedure on permanent maintenance.
(12) Birth certificates shall be completed according to the current Rules for the Administration of Vital Records, 20 CAR pt. 1, Department of Health.
(13)(A) A unit record system shall be maintained.
(B) A unit record is defined as all inpatient and outpatient visits for each patient being filed together in one (1) unit.
(14)(A) A policy and procedure manual for the Health Information Management Department shall be developed.
(B) The manual shall have evidence of ongoing review and/or revision.
(C) The first page of each manual shall have the:
(i) Annual review date; and
(ii) Signature of the Health Information Management Department supervisor and/or person or persons conducting the review.
(15)(A) A qualified individual shall be employed to direct the hospital’s Health Information Management Department.
(B) If a Registered Health Information Administrator (RHIA) or a Registered Health Information Technician (RHIT) is not employed as director on a full-time basis by the hospital, a consultant shall make periodic visits to:
(i) Evaluate functions of the Health Information Management Department; and
(ii) Train personnel.
(16) All patient records, whether stored within the Health Information Management Department or other areas, either within the facility or away from the facility, shall be protected from destruction by fire, water, vermin, dust, etc.
(17)(A) Medical records shall be considered confidential.
(B) Only authorized personnel shall have access to the medical records.
(C) All medical records, including those filed outside the Health Information Management Department, shall be secured at all times.
(D) If authorized personnel are not available, the Health Information Management Department shall be locked.
(E) Records shall be available to authorized personnel from the Department of Health.
(18) Release of medical information shall be restricted by the facility’s policies and procedures.
(19)(A) All medical records shall be retained in either the original, microfilm, or other acceptable methods for ten (10) years after the last discharge.
(B) After ten (10) years, a medical record may be destroyed provided the facility permanently maintains the information contained in the master patient index.
(C) Complete medical records of minors shall be retained for a period of two (2) years after the age of majority.
(20)(A) Procedures shall be developed for the retention and accessibility of the patients’ medical records if the hospital or other facility closes.
(B) The medical records shall be:
(i) Stored for the required retention period; and
(ii) Accessible for patient use.
(21)(A) All entries into the medical record shall be legible.
(B) There shall be no erasures or obliterations of the original information contained in a medical record.
(22) Medical records shall be complete and contain all required signed documentation, including physician reports, no later than thirty (30) days following the patient’s discharge date.
(23)(A) Patient records shall be destroyed by burning or shredding.
(B) Patient records shall not be disposed of in:
(i) Landfills; or
(ii) Other refuse collection sites.
(24) A QA/PI program shall be:
(A) Continuous; and
(B) Specific to the services.
(25)(A) In the event of a physician’s death or permanent incapacitation, incomplete medical records shall be reviewed in a manner approved by the medical staff.
(B) Approval to file incomplete medical records shall be obtained in a manner approved by the medical staff and a statement explaining the circumstances be placed in each record.
(b) Authentication of medical record entries.
(1)(A) Each entry into the medical record shall be authenticated by the individual who is the source of the information.
(B) Entries shall include:
(i) All documents, observations, notes; and
(ii) Any other information included in the record.
(2)(A) Signatures shall be at least the:
(i) First initial;
(ii) Last name; and
(iii) Title.
(B) Computerized signatures may be either by:
(i) Code;
(ii) Number;
(iii) Initials; or
(iv) The method developed by the facility.
(3)(A) The hospital’s medical staff and governing body shall adopt a policy regarding dictation that permits authentication by electronic or computer-generated signature.
(B) The policy shall identify those categories of the staff within the hospital who are authorized to authenticate patient records using electronic or computer-generated signatures.
(4)(A) At a minimum, the policy shall include adequate safeguards to ensure confidentiality.
(B) Each user shall be assigned a unique identifier that is generated through a confidential code.
(C) The policy shall include penalties for inappropriate use of the identifier.
(D) The user shall certify in writing that he or she is the only person authorized to use the signature code.
(E)(i) The hospital shall periodically monitor the use of identifiers.
(ii) The process by which the monitoring shall be conducted shall be described in the policy.
(5) The system shall make an opportunity available to the user to verify that the:
(A) Document is accurate; and
(B) Signature has been properly recorded.
(6) Each report generated by a user shall be separately authenticated.
(7) A user may terminate authorization for use of electronic or computer-generated signature upon written notice to the director of Health Information Services.
(8)(A) Rubber stamp signatures shall be acceptable if a letter from the physician is on file explaining that the:
(i) Physician shall be the only person using the stamp; and
(ii) Stamp shall remain in his or her possession at all times.
(B) The signature stamp shall be the full legal name of the physician with his or her professional title.
(9)(A) Transcribed reports dictated by other than the attending physician shall be signed by the:
(i) Credentialed individual dictating the report; and
(ii) Attending physician.
(B) Dictation of reports by other than the attending physician is limited to:
(i) History;
(ii) Physical;
(iii) Discharge summary; and
(iv) Progress notes.
(C) Reports dictated by resident physicians for training purposes require only the signature of the attending physician.
(c) Electronic health information.
(1) Policies and procedures governing electronic health information within the organization and with external entities shall be adopted by the governing body.
(2)(A) The policies and procedures shall provide for the use, exchange, security, and privacy of electronic health information.
(B) The policies and procedures shall provide for standardized and authorized availability of electronic health information for:
(i) Patient care;
(ii) Administrative purposes; and
(iii) Research.
(C) The policies and procedures will be in compliance with current guidelines and standards as established in federal and state statutes.
(d) Record content.
(1) Identification data shall include at least the following:
(A)(i) Patient’s full name.
(ii) Maiden name if applicable;
(B) Patient’s:
(i) Address;
(ii) Telephone number; and
(iii) Occupation;
(C) Date of birth;
(D) Age;
(E) Sex;
(F) Marital status (M.S.D.W.);
(G) Dates and times of admission and discharge;
(H) Full name of physician;
(I) Name and address of nearest relative or person or agency responsible for patient, and occupation of responsible party;
(J) Name, address, and telephone number of a person or persons to notify in case of emergency; and
(K) Medical record number.
(2)(A) A general consent for medical treatment and care.
(B) This shall be signed by the patient or guardian.
(C) Written or verbal consent shall not release the hospital or its personnel from upholding the rights of its patients, including but not limited to the right to:
(i) Privacy;
(ii) Dignity;
(iii) Security;
(iv) Confidentiality; and
(v) Freedom from abuse or neglect.
(3)(A) A consent for a do-not-resuscitate order or otherwise withholding or withdrawing treatment of a minor.
(B) The consent shall:
(i) Include the written or verbal consent of at least one (1) parent or guardian of the minor;
(ii) Include the signature of two (2) witnesses attesting the consent was given by at least one (1) parent or guardian when the consent was given verbally; and
(iii) Be documented in the minor’s medical record, specifying the:
(a) Parent or guardian who gave consent;
(b) Witnesses present; and
(c) Date and time the consent was obtained.
(C) The consent does not apply if the minor is:
(i) Married, pregnant, or emancipated;
(ii) Incarcerated in the Division of Correction or the Division of Community Correction; or
(iii) In custody of the Department of Human Services.
(D) Does not apply if a reasonably diligent effort of at least seventy-two (72) hours without success has been made to contact and inform each known parent or guardian of intent to:
(i) Issue a do-not-resuscitate order; or
(ii) Otherwise withhold or withdraw treatment so as to allow the natural death of the minor.
(E) The parent or guardian may revoke the consent verbally or in writing.
(4) Clinical reports shall include the following and shall comply with listed requirements:
(A)(i) A history and physical examination (HPE) shall be in the patient’s medical record within forty-eight (48) hours of the patient’s admission to the facility.
(ii) The HPE must be authenticated by the attending or treating physician and shall contain the following:
(a)(1) Family (medical) history and review of systems.
(2) If noncontributory, the record shall reflect such;
(b) Past medical history;
(c)(1) Chief complaint or complaints.
(2) A brief statement of the nature and duration of the symptoms that caused the patient to seek medical attention as stated in the patient’s own words;
(d) Present illness with dates or approximate dates of onset;
(e) Physical examination; and
(f) Provisional or admitting diagnosis or diagnoses;
(iii) History and physical examinations may be completed up to thirty (30) days prior to admission if the examination is updated at the time of admission.
(iv) The updated HPE must be authenticated by the attending or treating physician;
(B)(i) Progress notes shall be recorded, dated, and signed.
(ii) The frequency of the physician’s progress notes shall be determined by the patient’s condition.
(iii) Dictated progress notes:
(a) Are acceptable; and
(b) Shall be placed in the patient’s medical record within forty-eight (48) hours;
(C) Orders including verbal orders shall be authenticated with a legible and dated signature in a timely manner as defined by medical staff bylaws;
(D)(i) A discharge summary shall recapitulate:
(a) The significant findings and events of the patient’s hospitalization; and
(b) His or her condition on discharge;
(ii) The discharge summary must be authenticated by the attending or treating physician within thirty (30) days of the patient’s discharge.
(iii) The final diagnosis shall be stated in the discharge summary;
(E)(i) Autopsy findings shall be documented in complete protocol within sixty (60) days and the provisional anatomical diagnosis shall be recorded within seventy-two (72) hours.
(ii) A signed authorization for autopsy shall be obtained from the next of kin and documented in the medical record before an autopsy is performed;
(F)(i) Original, signed diagnostic reports (laboratory, X-rays, CAT scans, EKGs, fetal monitoring, EEGs) shall be filed in the patient’s medical record.
(ii) Physicians’ orders shall accompany all treatment procedures.
(iii) Fetal monitor and EEG tracings may be filed separately from the medical record if accessible when needed;
(G) Reports of ancillary services (dietary, physical therapy, respiratory care, social services, etc.) shall be included in the patient’s medical record; and
(H) Reports of medical consultation if ordered by the attending physician shall be included in the patient’s medical record within time frames established by the medical staff.
(e) Records of complementary departments. In addition to the general record content requirements stated above, subsections (f) – (g) of this section are required, as applicable.
(f) Surgery records.
(1)(A) A specific consent for surgery shall be documented prior to the surgery/procedure to be performed, except in cases of emergency, and shall include the:
(i) Date;
(ii) Time; and
(iii) Signatures of the patient and witness.
(B) Consent shall be:
(i) Obtained by the surgeon; and
(ii) Documented in the patient’s medical record.
(C) Abbreviations are not acceptable.
(2)(A) A history and physical examination (HPE) on admission containing medical history and physical findings shall be documented in the patient’s medical record prior to surgery.
(B)(i) In cases of emergency surgery, an abbreviated physical examination and a brief description of why the surgery is necessary shall be included in the HPE.
(ii) See subsection (d) of this section, record content.
(C) The HPE must be authenticated by the attending or treating physician or surgeon.
(3)(A) An anesthesia report, including preoperative evaluation and postoperative assessment, shall be documented by the anesthesiologist and/or certified registered nurse anesthetist (CRNA).
(B)(i) The preevaluation and post-assessment shall be dated and timed.
(ii) Preoperative anesthesia evaluation shall be completed prior to the patient’s surgery.
(iii) Report of anesthesia. A CRNA who has not been granted authority by a facility, as a United States Drug Enforcement Administration registrant, to order the administration of controlled substances shall give all orders as verbal orders from the:
(a) Supervising physician;
(b) Dentist; or
(c) Other person lawfully entitled to order an anesthetic.
(iv)(a) Postanesthesia assessment shall be documented in the medical record prior to the patient’s discharge, not to exceed forty-eight (48) hours after the patient’s surgery.
(b) If the patient is in need of continued observation, the anesthetist shall be readily available.
(c) Discharge criteria shall be established and approved by the medical staff and governing body.
(d) If the patient meets the discharge criteria within a three-hour period postoperatively, a postanesthesia assessment is not required.
(4)(A) An individualized operative report shall be:
(i) Written or dictated by the physician or surgeon immediately following surgery; and
(ii) Signed within seventy-two (72) hours.
(B) The report shall describe in detail:
(i) Techniques;
(ii) Findings;
(iii) Preoperative and postoperative diagnosis; and
(iv) Tissues removed.
(5)(A) A signed pathological report shall be maintained in the medical record of all tissue surgically removed.
(B) A specific list of tissues exempt from pathological examination shall be developed by the medical staff.
(g) Obstetrical records.
(1) A pertinent prenatal record shall be updated upon admission, or history and physical examination signed by the physician shall be:
(A) Available upon the patient’s admission; and
(B) Maintained in the patient’s medical record.
(2) A record of labor and delivery authenticated by the physician shall be maintained for every obstetrical patient.
(3) Documentation of the patient’s recovery from delivery shall be maintained.
(4) Nurses’ postpartum record, graphics, and nurses’ notes shall be maintained.
(h) Newborn records.
(1)(A) A newborn history and physical examination shall be completed by the physician within twenty-four (24) hours of birth.
(B) The following additional data shall be required:
(i) History of the newborn delivery (sex, date of birth, type of delivery, and anesthesia given the mother during labor and delivery); and
(ii) Physical examination (weight, date, time of birth, and condition of infant after birth).
(2) There shall be a consent for circumcision if applicable.
(3) A procedure note for circumcision shall be documented by the physician.
(4)(A) A discharge note or summary describing the condition of the newborn at discharge and follow-up instructions given to the mother must be prepared and included in the medical record.
(B) The discharge note or summary must be authenticated by the attending or treating physician.
(5)(A) Hospitals shall comply with state law and Department of Health requirements for newborn testing.
(B) See:
(i) Rules Pertaining to Testing of Newborn Infants, 20 CAR pt. 107; and
(ii) Arkansas Code § 20-15-301 et seq.
(6) Birth certificates shall be completed on all infants born in the hospital, or admitted as a result of birth, in accordance with the requirements of the Division of Vital Records of the Department of Health.
"EEG" means electroencephalogram.
"EKG" means electrocardiogram.