La. Admin. Code tit. 50 § II-10135

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-10135 - Medical Records

A. The facility shall maintain medical records which include clinical, medical, and psychosocial information on each resident.

1. These records must be:

a. complete;

b. accurately documented;

c. readily accessible; and

d. systematically organized.

2. Facilities shall have written policies and procedures governing access to, duplication of, and dissemination of information from the resident's personal and medical records.

B. Availability of Records

1. The facility shall make necessary records available to appropriate state and federal personnel at reasonable times. Records shall include but shall not be limited to the following:

a. personal property and financial records; and

b. all medical records

NOTE: This includes records of all treatments, drugs, and services for which vendor payments have been made, or which are to be made, under the Medical Assistance Program. This includes the authority for and the date of administration of such treatment, drugs, or services. The facility shall provide sufficient documentation to enable DHH to verify that each charge is due and proper prior to payment.

c. All other records which DHH finds necessary to determine a facility's compliance with any federal or state law, rule, or regulation promulgated by the Department of Health and Human Services (DHHS) or by DHH.

2. Overall supervisory responsibility for the resident record service is assigned to a responsible employee of the facility. If the resident record supervisor is not a qualified medical record practitioner, this person functions with consultation from a person so qualified minimum consultation time shall not be less than one hour per quarter.

C. Availability of Medical Records to Facility Staff. The facility shall ensure that medical records are available to licensed staff directly involved with the resident's care.

D. Confidentiality. Facilities shall ensure confidential treatment of personal and medical records, including information contained in automatic data banks. The written consent of the resident or his/her legal representative shall be required for the release of information to any persons not otherwise authorized under law to receive it.

E. Protection of Records. The facility shall protect records against loss, damage, destruction, and unauthorized use.

F. Retention of Records. The facility shall retain records for:

1. in the case of minors, three years after they become 18 years of age; and

2. six years after the date of discharge.

G. Components of Medical Records. Each medical record shall consist of the active medical chart and the facility medical files or folders.

1. Active Medical Charts

a. The active medical charts shall contain the following information:

i. three to six months of current pertinent information relating to the active ongoing medical care;

ii. physician certification of each medical assistance admission;

iii. physician recertification that the resident required the services of the facility;

iv. certification that each plan of care has been periodically reviewed and revised; and

v. if the facility is aware that an resident has been interdicted, a statement to this effect shall be noted in a conspicuous place in the active medical chart.

2. Medical Files. As the active chart becomes bulky, the outdated information shall be removed and filed in the facility's medical files or folders.

H. Contents of Medical Records. An organized active record system shall be maintained for each resident. It shall include the following identifying information:

1. full name;

2. home address, including street address, city, parish, and state;

3. social security number;

4. medical identification number;

5. medicare claim number, if applicable;

6. marital status;

7. date of birth;

8. sex;

9. religious preference;

10. birthplace;

11. father's name;

12. mother's maiden name;

13. name, address, and telephone number of referral agency or hospital;

14. personal attending physician and alternate, if possible;

15. choices of other service providers;

16. name and address of next of kin or other legal representative or sponsor;

17. admitting diagnosis;

18. current diagnosis, including primary and secondary DSM III diagnosis, if applicable;

19. date of death;

20. cause of death;

21. diagnosis at death;

22. copy of death certificate;

23. disposition of body;

24. name of funeral home, if appropriate; and

25. any other useful identifying information.

La. Admin. Code tit. 50, § II-10135

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 22:34 (January 1996).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153.