UTAH ADMIN. CODE §432-100-33 - Medical records

Hospitals must retain medical records for 7 years. Medical records of minor patients must be kept for 4 years past the minor’s 18 birthday, but not less than 7 years.
 
The hospital’s medical records department shall retain through employment or consultation the services of either a Registered Health Information Administrator or a Health Information Technician. Consultants must submit quarterly written reports to the hospital administrator.
 
The records department is responsible for providing secure storage, controlled access, and prompt retrieval. Records should only be made available to medical staff, authorized personnel, persons authorized by the patient through consent form, and to Department compliance and licensing investigators.
 
Records should be indexed according to diagnosis, procedure, demographic information, practitioner, and shall be current within six months of patient discharge. Original records are hospital property and may only be removed pursuant to court order or subpoena. Record entries must be legible, complete, authenticated, and dated by the author.
 
Medical records should be reviewed at least quarterly for completeness, accuracy, and to ensure adherence to hospital policy. Records should be completed within 30 days of discharge. Prior to destroying records, the hospital must publish a notice in the newspaper once a week for three consecutive weeks to allow former patients to retrieve their records.
 
The hospital shall retain a permanent master patient index including the following:
·         Patient’s name
·         Medical record number
·         Date of birth
·         Dates of admission and discharge
·         Name of attending physician(s)
 
Each medical record must contain the following:
·         Patient identification data
·         Medical history and physician examinations
·         Diagnoses
·         Documentation of complications
·         Consent forms
·         Information regarding advanced directives
·         Practitioner orders, notes, reports and vital signs
·         Discharge summary