Medical Records - 31-4-18 R.I. Code R. § 27

Licensed Rhode Island hospitals must:

• Appoint a “registered medical record administrator or a registered health information administrator (RHIA)…certified by the American Health Information Management Association” to oversee the hospital’s medical record service.
• Maintain staff and equipment sufficient to carry out necessary medical record activities (e.g. processing, retrieving, etc.).
• Maintain medical records for every patient treated in the hospital and make the record available to all hospital units.
• Establish policies and procedures regarding medical record content and completion.
• Ensure that medical record completion is limited to appropriate persons, as defined by hospital policies.
• Include information in the medical record that is sufficient to identify the patient, problem, treatment, and outcome.
• Comply with standards for the content of the medical records as established in the Joint Commission on Accreditation of Health Care Organizations “Accreditation Manual for Hospitals.” Additionally, medical records must identify the patient’s primary language, whether the hospital has provided interpretive services, and/or whether the hospital was unable to provide interpretive services.
• Complete the medical record and discharge summary within 30 days of discharging the patient.
• Store medical records in compliance with the standards established in the National Fire Protections Association’s “Protection of Records.”
• Maintain medical records for at least five years following an adult patient’s discharge and for at least five years after a child patient reaches the age of 18.
• Implement measures to ensure the confidentiality of all medical records.
• Provide patients or their representatives with copies of their medical records within 30 days of receiving a medical record request. Hospitals may charge patients for their records unless the request relates to a school immunization requirement, and application for government benefits, or a Worker’s Compensation Claim.
• Issue a press release within 30 days of closing or changing ownership that notifies patients about the procedure for obtaining their medical records.