Medical record services – Wis. Admin. Code DHS §124-14

Medical Record Services at Hospitals

This law requires that hospitals maintain a medical record for each admitted patient, and that this record be kept confidential and released only in accordance with the law.  The law further requires that these records be maintained by the hospital's medical records service.  The law prohibits release of medical records by the service without the written consent of the patient, and further prohibits the removal of the records from the hospital premises except by authorized persons acting according to a subpoena/court order/to perform contracted services.  The law requires that there be a written policy about the preservation of medical records, and that medical records be maintained for at least 5 years.  The law demands that the hospital employ as many persons as necessary to operate this service properly.  The law then sets forth certain specific requirements for coding, indexing and access to the records.

Medical records are required to contain information including but not limited to:

• Patient identification information
• Medical complaints
• Health history
• Physical exam findings
• Diagnosis and diagnostic orders
• All lab work and reports
• Consultation reports
• Notes by physicians and non-physicians involved in patient care to provide picture of patient’s progress
• Final diagnosis
• Discharge summary
• Autopsy findings and organ donation information, where applicable

Maternity patient and newborn records require certain additional information.  The law allows only members of medical staff and other authorized professionals to make entries in a patient’s medical record, and requires certain signatures to further authenticate the medical record.  The law requires that the records be completed promptly, legibly, with the appropriate date and signatures.