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Requirements for Medical Record Maintenance and Administration in Hospitals – 410 Ind. Admin. Code 15-1.5-4
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Current as of June 2015
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The medical record services has administrative responsibility for the medical records that are maintained for every individual evaluated or treated within those services that come under the hospital’s license. The service should be directed by a registered health information administrator or a registered health information technician. It should also be provided with the necessary direction, staffing and facilities to perform all required functions in order to ensure prompt completion, filing and retrieval of records.
The medical record itself should be maintained with documentation of service rendered for every individual who is evaluated or treated at the hospital. It must be documented accurately and in a timely manner, be readily accessible, and permit prompt retrieval of information. The record should reflect a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. Each entry should be authenticated promptly in accordance with hospital policy. The hospital must ensure the confidentiality of all patient records, which includes procedures for releasing information only to authorized individuals, and ensuring that unauthorized individuals cannot gain access to patient records
The medical record should contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and document accurately the course of treatment and results. All entries should be legible, complete, dated, and made by individuals with the authority to do so by hospital and medical staff policies. Inpatient records should include diagnostic and therapeutic orders, informed consent documents when necessary, progress notes, clinical observations, operative notes, results of all consultative evaluations, nursing notes, reports of pathology and laboratory examinations, documentation of complications and unfavorable reactions to drugs, discharge summaries and a final diagnosis.
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Current as of June 2015
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