Medical record services, N.D. Admin Code 33-07-01.1-20

Medical record services, 
 
Requires general acute hospitals to maintain confidential medical records for all admitted patients. Limits record access to authorized personnel. Permits disclosure of medical information with a patient’s written consent and removal of medical records from the hospital only pursuant to a court order or subpoena. Establishes standards for the time of medical record maintenance (e.g., at least 10 years following the date on which a patient last received treatment). Specifies the content that hospitals must include in each medical record (e.g., diagnosis, family history, lab reports, discharge information, etc.). Requires the authentication of medical record entries by the person that made the entry. Permits the use of electronic signatures for authentication so long as the hospital’s governing body adopts an appropriate electronic signature policy that addresses the safeguarding of confidentiality and record accuracy. Specifies the timeframe for completing entries within medical records (e.g., Information regarding the patient’s past history and physical examination must be entered within 24 hours of their admission).