N.D. Admin. Code § 33-07-01.1-20

Medical Records Services

The general acute hospital, including primary care and specialized hospitals, must have a medical records service that ensures that medical records are maintained and kept confidential, only accessible to authorized personnel, only released pursuant to written consent of the patient, and not removed from the hospital except upon subpoena or court order. Furthermore, if a hospital discontinues operation, it shall make known to the department where its records will be stored for at least ten (10) years after the closure date. Patient must be given notice (via legal notice and display advertisement in a newspaper of general circulation) that they may obtain their records before the record is destroyed.

Unless a medical record relates to any pending litigation, records must be preserved for ten (10) years from the date that the patient in question was last treated in the hospital, except for where a patient was less than eighteen years of age at the time of last treatment, in which case the hospital may dispose of the patient record on or after the date of the patient's twenty-first birthday or on or after the tenth anniversary of the date on which the patient was last treated, whichever is later. It is the governing body’s duty to identify records that should be preserved beyond the above-identified timeframes.

The hospital’s records service must be organized by a registered or accredited records technician responsible for evaluating the records and operation of the system and ensuring that personnel are available so that records can be promptly retrieved from the hospital’s system of identification and filing. Each record should centralize all clinical information pertaining to a patient's hospitalization upon discharge, with the original of all reports filed in the medical record. Records are to be current within six months of discharge and must be retrievable by disease, operation, and licensed health care practitioner.

The medical records must contain sufficient information to justify the diagnosis and warrant the treatment and end results. The medical records must contain the following information, with sufficient detail, in order to justify diagnosis, treatment, and end results:

• identification data;
• chief complaint, to include a concise statement of patient’s complaints and the date of onset and duration of each;
• present illness;
• past history, family history;
• physical examination, including all findings resulting from an inventory of systems, and provisional diagnosis reflecting the examining licensed health care practitioner's evaluation of the patient's condition;
• treatment& progress notes that give a chronological picture of the patient's progress, the delineation of the course and results of treatment, and indicate all diagnostic and treatment procedures;
• final diagnosis expressed in the terminology of a recognized disease nomenclature;
• discharge summary, recapitulating the significant findings and events of the patient's hospitalization and the patient's condition on discharge;
• nurses' notes, clinical laboratory reports, x-ray reports, consultation reports (a written opinion signed by the consultant), surgical and tissue reports and applicable autopsy findings; and
• all medical and dental records attributable to a dental patient.

All entries into the medical record must be authenticated by the individual who made the written entry. Written entries by health care practitioners must be personally signed and dated. Telephonic or verbal orders given to qualified licensed personnel must be transcribed, dated, timed, and signed by a licensed practitioner within forty-eight (48) hours, unless hospital policy provides for a read-back verification, which must be verified within thirty (30) days. If an entry is made by a medical student or unlicensed resident, the attending practitioner shall countersign at least the history and physical examination and summary. Signature stamps may be used according to hospital policy so long as there is written assurance on file that the licensed health care practitioner is the sole user of the signature stamp.

Electronic signatures may be utilized if the hospital's medical staff and governing body adopt a policy that permits authentication by electronic signature. The policy must indicate which staff within the hospital are authorized to authenticate patients' medical records using electronic signatures, as well as safeguards to ensure confidentiality, including:

• Assigning each user a unique, confidential identifier;
• Written certification by the hospital that each identifier is kept strictly confidential, as well as a termination policy for misuse;
• Written user certification that the user is the only individual with user access to the identifier and the only individual authorized to use the signature code;
• Monitoring the use of the identifiers periodically and take corrective action as needed, per established policy; and
• A certification process for entries made into medical records, including confirmation of document completion, accuracy verification, and periodic system integrity checks.

A user may terminate authorization for use of an electronic signature upon written notice to the staff member in charge of medical records or other person designated by the hospital's policy.

Each report generated by the user must be separately authenticated and coded according to safeguards promulgated by hospital administration. Current and discharged patient records must be completely promptly; past history and physical examination information must be completed within twenty-four (24) hours and all records must be completed and filed no later than thirty (30) days after discharge. If a patient is readmitted within a month's time for the same conditions, reference to the previous history with an interval note and physical examination suffices.