MO. CODE REGS. ANN. tit. 19, § 30-20.094 - Medical records in hospitals under the Department of Health and Senior Services regulations

The regulation above provides minimum requirements for medical records maintained in hospitals. 

Under the Hospital Licensing Law, hospitals must maintain adequate medical records for each patient in order to be licensed for operation.  Hospital licenses are issued for up to one year, and if, during inspection, a hospital is found to be in non-compliance with the Hospital Licensing Law, including the provision requiring maintenance of adequate medical records, a hospital’s license could be suspended.

According to the regulations, medical records must be maintained on each patient at the hospital, documenting all instances of patient care provided by hospital staff.  More specifically, the regulations state that the medical record for each patient must include at least the following:

• unique identifying record number
• pertinent identifying and personal data for the patient
• history of present illness or complaint
• how the injury occurred
• past history
• family history
• physical examination
• admitting diagnosis
• medical staff orders
• progress notes
• nurses’ notes
• discharge summary
• final diagnosis
• evidence of informed consent

According to the regulation, medical records are considered the property of the hospital and must be preserved in a permanent file in a format that may include electronic media.  Patients’ records shall be retained for a minimum of 10 years, with the exception of minor patient’s records, which must be retained until the minor’s 23^rd birthday, or for a period of 10 years, whichever occurs later.  Written consent of a patient is required in order to access or release a patient’s medical record to individuals who are not otherwise authorized to view it.

Additional requirements for the medical record include a requirement that a history and physical examination be completed on each inpatient within twenty- four (24) hours of admission.  Alternatively, a history and physical examination completed or updated within the seven (7) days prior to admission will be accepted, or a history and physical which performed up to thirty (30) days before admission, provided that the patient is reassessed and an update note is written, signed and dated to reflect the patient’s status within seven (7) days prior to, or within twenty-four (24) hours after, admission.  Also, a patient’s records shall be completed within thirty (30) days of discharge