Programmatic Functions - 6 COLO. CODE REGS. § 1011-1: IV-8.102

Medical records must be stored to be protected from unauthorized use and disclosure and to preserve the confidentiality of information. Medical records must be preserved as originals or electronically for 10 years after the most recent care encounter, and for minors, the period of minority plus 10 years or 10 years after the most recent care encounter, whichever is later.   After the required retention period, records may be destroyed at the facility’s discretion.  However, the facility must have a policy in place to notify patients before their records are destroyed.  If a facility ceases operation, there must be policies in place to allow for secure storage of medical records and easy retrieval.  The facility must publish record retrieval instructions in the newspaper. 
 
All diagnostic, treatment and care orders must be properly signed by a physician or licensed practitioner.  Records must be promptly completed by the physician or practitioner, and must be authenticated by a signature, initials or computer key. 
 
Patient records must include the following:
·         Adequate identification, including sociological data;
·         Chief complaint and present illness;
·         Medical history;
·         Physical examination reports;
·         Reports of special exams, including clinical and pathological lab findings;
·         Written report of diagnostic imaging tests;
·         Reports of consulting physicians;
·         Treatment and progress reports;
·         Findings of other treatment staff;
·         Progress or treatment notes;
·         Medications;
·         Signed informed consent forms;
·         Final and secondary diagnosis;
·         Disposition of the case ands follow-up care;
·         Autopsy, if applicable;
·         Rehabilitation service records, if applicable.
 
Inpatient records must also include date and time of admission and discharge, admission diagnosis and discharge plan and summary.  Surgery patient records must include history, special examination and condition before surgery, anesthesia record, operative findings, and pathologist report on removed tissue.  The law also sets forth details on information required to be reported on obstetrics patients, newborns, and psychiatric patients.
 
Hospitals must also record the following:
·         Daily census;
·         Admission and discharge analysis;
·         Chronological register of all live births and stillbirths;
·         Register of all surgeries;
·         Diagnostic index;
·         Physician index;
·         Death register;
·         Outpatient and emergency room admission register.