Health Information Services - ARK. CODE R. 007.05.17-14

Hospital records must be maintained for each patient 10 years after discharge. The facility must permanently maintain information in a Master Patient Index. The medical records of minors must be kept for 2 years after the patient reaches the age of majority. Patient records must be stored in a way to protect them from destruction. Medical records are confidential, and only authorized personnel shall have access. Medical information may only be released according to the facility’s policies and procedures. Medical records should be maintained in original format. Patient records may only be destroyed by burning or shredding, they may not be disposed of in landfills.
Each entry into a medical record must be authenticated by the source of the information. The facility must adopt a policy that allows for authentication by electronic or computer generated signature.
The facility must adopt policies and procedures regarding electronic health information, including the use, exchange, security, and privacy of such.
Each medical record must contain the following:
·         The patient’s full name
·         The patient’s address
·         Date of birth
·         Age
·         Sex
·         Marital status
·         Dates of admission and discharge
·         Name of physician
·         Contact information for nearest relative or responsible party
·         Emergency contact; and
·         Medical record number
Each patient must sign a general consent form for medical treatment.
Clinical reports must comply with specific requirements.