Medical record services under the Alabama State Board of Health regulations - ALA. ADMIN. CODE r. 420-5-7-.13

A hospital must have a medical record service to maintain medical records for each inpatient and outpatient. Medical records must be accurate, promptly completed, properly filed, and accessible.  The hospital must ensure the integrity and security of the medical records.  Medical records must be retained for at least five years. In the case of minor patients, medical records must be retained for at least 5 years after the patient has reached adulthood.
 
The hospital must have a process of coding and indexing the medical records to allow for easy retrieval by diagnosis or procedure, and to support medical care evaluation studies. 
 
The hospital must also have a process in place to ensure the confidentiality of patient medical records.  Information from medical records may only be released to authorized individuals.  The hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. 
 
Patient medical records must contain information to justify admission and continued hospitalization, describe the patient’s progress and reaction to medications and treatments.  All patient medical records must be dated, timed and authenticated by the person responsible for providing the service.  All orders must be dated, timed, and authenticated, even if they are verbal orders. 
 
All records must document:
·         A medical history and /or physical exam;
·         An updated examination of the patient, including changes in the patient’s condition;
·         Admitting diagnosis;
·         Results of all evaluations;
·          Documentation of complications, including hospital acquired infections and negative reactions to medication;
·         All practitioner orders;
·         Discharge summary;
·         Final diagnosis with completion of medical records.
 
The hospital must have a plan to transfer all medical records to another facility in the event the hospital closes.