37.106.1105 MEDICAL ASSISTANCE FACILITIES: MEDICAL RECORDS
(1) A medical assistance facility must maintain a medical records system in accordance with written policies and procedures and meeting the following standards:
(a) The facility must employ adequate personnel to ensure prompt and systematic completion, filing, and retrieval of records.
(b) If the medical record supervisor is not a record administrator or technician registered or accredited by the American medical record association (AMRA) , the facility must ensure that the supervisor receives consultation from an AMRA registered record administrator or accredited record technician.
(c) The facility must create and maintain a record for each person receiving health care services from the facility that includes, if applicable:
(i) identification and social data;
(ii) admitting diagnosis;
(iii) pertinent medical history;
(iv) properly executed consent forms;
(v) reports of physical examinations, diagnostic and laboratory test results, and consultation findings;
(vi) all physician's orders, nurses' notes, and reports of treatments and medications;
(vii) final diagnosis;
(viii) discharge summary; and
(ix) any other pertinent information necessary to monitor the patient's prognosis.
(d) Each record must include the signatures of the physician or other health care professional authoring the record entries.
(e) Records of a discharged patient must be completed within 30 days of the discharge date.
(f) The facility must have written policies and procedures ensuring the confidentiality of patient records, and safeguards against loss, destruction, or unauthorized use, in accordance with applicable state and federal law and including policies and procedures which:
(i) Govern the use and removal of records from the record storage area;
(ii) Specify the conditions under which record information may be released and to whom;
(iii) Specify when the patient's written consent is required for release of information, in accordance with Title 50, chapter 16, part 5, MCA, the Uniform Health Care Information Act.
History: Sec. 50-5-103, MCA; IMP, Sec. 50-5-101, 50-5-103 and 50-5-204, MCA; NEW, 1989 MAR p. 663, Eff. 4/28/89; TRANS, from DHES, 2002 MAR p. 185.