S.C. Code Regs. § § 61-91.700.703

Current through Register Vol. 48, No. 11, November 22, 2024

Section 61-91.700.703 - Record Maintenance

A. The licensee shall provide accommodations, space, supplies, and equipment adequate for the protection, security, and storage of patient records.

B. When a patient is transferred to an emergency facility, a transfer summary to include, at a minimum, the diagnosis and medication administration record, shall accompany the patient to the receiving facility at the time of transfer or forwarded immediately after the transfer. Documentation of the information forwarded shall be maintained in the facility's patient record. (I)

C. The patient record is confidential. Records containing protected or confidential health information shall be made available only to individuals granted access to that information, in accordance with state and federal laws. The facility shall have a written policy designating the persons allowed to access confidential patient information. (II)

D. Records generated by organizations or individuals contracted by the facility for care, treatment, procedures, surgery, and/or services shall be maintained by the facility that has admitted the patient. Appropriate information shall be provided to assure continuity of care.

E. The facility shall determine the medium in which information is stored. The information shall be readily retrievable and accessible by facility staff, as needed, and for regulatory compliance inspections.

F. Upon discharge of a patient, the record shall be completed within 60 days and filed in an inactive/closed file maintained by the licensee. Prior to the closing of a facility for any reason, the licensee shall arrange for preservation of records to ensure compliance with these regulations and other applicable law. The licensee shall notify the Department, in writing, describing these arrangements and the location of the records.

G. Records of patients shall be maintained for at least six years following the discharge of the patient. Other documents required by the regulation, e.g., fire drills, shall be retained at least 12 months or until the next Department inspection, whichever is longer.

H. Patient records are the property of the facility; the original record shall not be removed without court order. (II)

S.C. Code Regs. § 61-91.700.703

Amended by State Register Volume 39, Issue No. 06, eff. 6/26/2015; State Register Volume 48, Issue No. 06, eff. 6/28/2024.