SC ADC 61-16, § 1104 - Medical Records and Reports

It is the responsibility of each attending physician to timely complete and sign a medical record. A rubber stamp signature can be used only if the physician whose signature the rubber stamp represents is the only one who has possession and use of it, and the hospital’s administrative office possesses a statement signed by the physician confirming he is the only one who possesses and uses the stamp. Signature stamps cannot be used on orders for drugs listed as "controlled substances" under R61-4 of the South Carolina Code of Laws of 1976.

Supervision, filing and indexing of medical records are the responsibility of a hospital employee who has had training in this field.

Medical records shall be properly indexed and filed for ready access by members of the staff.

Records of patients are the property of the facility and must not be taken from the hospital property except by court order.

Adequate and complete medical records shall be legibly written or typed and signed for all patients admitted to the hospital and newborns delivered in the hospital. Readily identifiable initials in lieu of nurses’ signatures are acceptable, but not encouraged.

A minimum medical record shall include:

• An admission Record, which includes the patient’s name, address, & background information; family history; health insurance number; social security number; a provision diagnosis; the name of the person providing information; emergency contact information; name and address of referring physician; name, address and telephone number of attending physician; and date and hour of admission;
• A history and physical within 48 hours after admission;
• A provisional or working diagnosis;
• Pre-operative diagnosis;
• Medical treatment;
• Complete surgical record, including technique of operation and findings, and post-operative diagnosis and condition;
• Report of anesthesia;
• Nurses' notes;
• Progress notes;
• Gross pathological findings and microscopic;
• Temperature chart, including pulse and respiration;
• Record or similar document for recording of medications, treatments and other pertinent data. Nurses must sign this document after each medication administration;
• Final diagnosis and discharge summary, including date and hour of discharge;
• In the case of death, cause and autopsy findings, if autopsy is performed; and
• Special examinations, if any such as: consultations, clinical laboratory, X-ray and other examinations.

Newborn records should include:

• History of hereditary conditions in mother's and/or father's family;
• First day of the last menstrual period (L.M.P.) and estimated day of confinement (E.D.C.);
• Mother's blood group and RH type;
• Serological test for syphilis (including dates performed);
• Number, duration and outcome of previous pregnancies, with dates;
• Maternal disease (e.g., diabetes, hypertension, preeclampsia, infections);
• Drugs taken during pregnancy, labor and delivery;
• Results of measurements of fetal maturity and well-being;
• Duration of ruptured membranes and labor, including length of second stage;
• Method of delivery, including indications for operative or instrumental interference;
• Complications of labor and delivery, including a representative strip of the feta) ECG if recorded;
• Description of placenta at delivery, including number of umbilical vessels;
• Estimated amount and description of amniotic fluid;
• Apgar scores at 1 and 5 minutes of age. Description of resuscitations, if required; detailed description of abnormalities and problems occurring from birth until transfer to the special nursery or the referral facility;
• Test results and date specimen was collected for PKU and hypothyroid newborn screening test. (Exempt only when parents object because of religious convictions, to be noted in file).

All medical records must contain the orders for medication and treatment written in ink and signed and dated by the prescriber or his designee. All orders, including verbal orders, shall be properly recorded in the medical record and dated and signed by the prescriber or designee within 48 hours.

Medical records must be stored in an environment preventing unauthorized access and deterioration. Records are confidential and must be kept for 10 years. Records may be destroyed after 10 years provided that if they are the records of minors they are kept until after the expiration of the period of election following achievement of majority as prescribed by statute, and the hospital retains an index, providing such basic information as dates of admission and discharge, name of responsible physician, and record of diagnosis and operations for all destroyed records.

If a hospital reduces the record to microfilm before 10 years have expired, the microfilm must contain the full record.

In the event of change of ownership, all medical records shall be transferred to the new owners.  Before closing, the facility must ensure records are preserved. The facility shall notify the Department, in writing, describing these arrangements.

In order to contribute to the continuity of quality care, procedures must be established and implemented to provide discharge summaries and/or other appropriate information to health care providers to whom patients are discharged, transferred or referred.