Title 7 . Health and Social Services

Chapter 12 . Assistance for Community Health Facilities

Section 770. Medical record service

7 AAC 12.770. Medical record service

(a) Each facility, with the exception of home health agencies, intermediate care facilities for the mentally retarded, and birth centers, must have a medical record service which complies with the provisions of this section.

(b) A facility must keep records on all patients admitted or accepted for treatment. Originals or accurate reproductions of the contents of the originals of all records, including x-rays, must be maintained in a form which is legible and readily available upon the request of the attending physician, medical staff, representative of the department, or, upon the patient's written request, to other practitioners.

(c) Each in-patient medical record must include, as appropriate

(1) an identification sheet which includes the

(A) patient's name;

(B) medical record number;

(C) patient's address on admission;

(D) patient's date of birth;

(E) patient's sex;

(F) patient's marital status;

(G) patient's religious preference;

(H) date of admission;

(I) name, address, and telephone number of a contact person;

(J) name of the patient's attending physician;

(K) initial diagnostic impression;

(L) date of discharge and final diagnosis; and

(M) source of payment;

(2) a medical and psychiatric history and examination record;

(3) consultation reports, dental records, and reports of special studies;

(4) an order sheet which includes medication, treatment, and diet orders signed by a physician;

(5) progress notes for each service or treatment received;

(6) nurses' notes which must include

(A) an accurate record of care given;

(B) a record of pertinent observations and response to treatment including psychosocial and physical manifestations;

(C) an assessment at the time of admission;

(D) a discharge plan; and

(E) the name, dosage, and time of administration of a medication or treatment, the route of administration and site of injection, if other than by oral administration, of a medication, the patient's response, and the signature of the person who administered the medication or treatment; and

(F) a record of any restraint used, showing the duration of usage;

(7) court orders relevant to involuntary treatment;

(8) laboratory reports;

(9) x-ray reports;

(10) consent forms;

(11) operative report on in-patient and out-patient surgery including pre-operative and post-operative diagnosis, description of findings, techniques used, and tissue removed or altered, if appropriate;

(12) anesthesia records including pre-operative diagnosis and post-anesthesia follow-up;

(13) a pathology report, if tissue or body fluid is removed;

(14) recovery room records;

(15) labor record;

(16) delivery record;

(17) record of a neonatal physical examination and condition on discharge;

(18) if the patient was in inpatient care for 48 hours or more, a discharge summary, prepared and signed by the attending physician or mid-level practitioner, that summarizes

(A) significant findings and events of the patient's stay in the facility;

(B) conclusions as to the patient's primary and any associated diagnoses; and

(C) disposition of the patient at discharge including instructions, medications, and recommendations and arrangements for future care; and

(19) if the patient was in inpatient care for less than 48 hours, a final discharge progress note signed by the attending physician or mid-level practitioner.

(d) A facility must maintain procedures to protect the information in medical records from loss, defacement, tampering, or access by unauthorized persons.

(e) A record must be completed within 15 days of discharge and authenticated or signed by the attending physician or dentist. A record may be authenticated by a signature stamp or computer key instead of a physician's signature when the physician has given a signed statement to the hospital administration that he or she is the only person who

(1) has possession of the stamp or key; and

(2) may use the stamp or key.

(f) Records must be indexed in accordance with standard medical record nomenclature.

(g) A transfer summary, signed by the physician, must accompany the patient if the patient is transferred to another facility or if transferred to a nursing or intermediate care service unit within the same facility. The transfer summary must include essential information relative to the patient's diagnosis, condition, medications, treatments, dietary requirement, known allergies, and treatment plan.

(h) Each facility subject to the provisions of this section, with the exception of ambulatory surgical facilities, must employ the services of a records administrator who is registered by the American Health Information Management Association or a record technician who is accredited by the American Health Information Management Association to supervise the medical record service and, if the administrator or technician is a consultant only, to make visits to the facility not less than biannually to organize and evaluate the operation of the service and to provide written reports to the medical record service and the administration of the facility.

History: Eff. 11/19/83, Register 88; am 5/4/97, Register 142

Authority: AS 18.05.040

AS 18.20.010

AS 18.20.060

AS 18.20.085

Editor's note: Verification of registration status as a registered records administrator or an accredited record technician may be obtained from the American Health Information Management Association at 919 North Michigan Ave., Suite 1400, Chicago, IL, 60611-1683.