Ala. Admin. Code r. 420-5-18-.06

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-18-.06 - Medical Records

(1)Patient Charts. Charts should be well-organized and the information in them easily accessible. Materials such as questionnaires, sleep and temperature logs, and psychological tests should be made part of the patient's chart.

(2)Narrative Entries. Narrative entries must be included in the patient chart to document all patient contacts, to review results, and to record diagnosis, treatment plan, and mode of implementation. Patient intake information must be included in each chart and include appropriate histories and physicals.

(3)Diagnostic Information. All diagnostic information, regardless of its state of development during the course of the work-up, should be in written form. A consulting cardiologist, for example, should be required to submit a written report. All clinical information relative to a patient's sleep study and treatment shall be documented in a single patient chart and stored in the sleep disorder facility until the file becomes inactive. Active patient charts should be readily available at all times.

(4)Summary. A written summary of each case must be placed in the chart by the responsible physician at the time that treatment recommendations or procedures are undertaken. Summaries should include not only a description of the procedure performed, but also a soundly reasoned analysis of the clinical significance of these procedures and their implications for the management of the patient.

(5)Statement of Follow-up Plan. The patient's record must contain a description of follow-up procedures, whether or not the treatment is executed by the facility. If the facility is not providing the treatment, the record must be explicit as to how contact will be maintained with the patient or referring source. In order to ensure that the highest quality care is being provided, a formal, efficient, and effective vehicle must be used by staff physicians to convey the results of the evaluation and treatment options to the patient and the physician or others who referred the patient to the facility. Consequently, each patient's chart should have a copy of the correspondence which states the diagnostic assessment of the patient and a recommended treatment plan if the disorder has a known treatment. This communication should be sent with a reasonable time after the completion of the evaluation.

(6)Final Diagnosis. All final Diagnoses must be made using ASDA nosology as established in a current International Classification of Sleep Disorders Diagnostic and Coding Manual.

(7)Storage and Safety. Provisions shall be made for the safe storage and confidentiality of records.

(8)Retention of Records. Medical records must be retained in their original or legally reproduced form for a period of at least five years.

(9)Proposed Plan for Disposition for Medical Records. When a sleep disorders facility ceases to operate, either voluntarily or by revocation of its license, the governing body (licensee) at or prior to such action shall develop a proposed plan for the disposition of its medical records. Such plan shall be submitted for review and approval to the Division of Licensure and Certification and shall contain provision for the proper storage, safeguarding and confidentiality, transfer and/or disposal of patient medical records.

Author:

Ala. Admin. Code r. 420-5-18-.06

New Rule: Filed November 20, 1996; effective December 24, 1996.

Statutory Authority:Code of Ala. 1975, Title 22, Chapter 21.