W. Va. Code R. § 69-8-11

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 69-8-11 - Records

11.1. The pain management clinic shall maintain patient records and business records according to clinic policy. Clinic policy shall be in compliance with state and federal law, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

11.2. The pain management clinic shall establish policies and procedures specifying who may use the records, under what conditions the records may be removed from the clinic and under what conditions the information from the records may be released.

11.3. The pain management clinic shall establish procedures to ensure security of all records, including electronic records.

11.4. The pain management clinic shall establish and maintain a recordkeeping system that is adequate to document and monitor patient care. The system shall comply with all federal and state reporting requirements relevant to prescription drugs approved for use in treatment of chronic pain management.

11.5. Patient records shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and results of treatment accurately.

11.6. Patient records shall be current and easily accessible from admission through discharge.

11.7. Patient records shall include, at a minimum:

11.7.1. Patient identification and demographic data;

11.7.2. Properly executed informed consent forms for procedures and treatments;

11.7.3. Copy of signed patient rights;

11.7.4. A complete patient history and physical examination, including any history of drug abuse or dependence;

11.7.5. Patient assessments and plans of care;

11.7.6. Progress notes and practitioners' orders;

11.7.7. Diagnostic, therapeutic, and laboratory results, including drug testing results;

11.7.8. Reports of evaluations, consultations, and hospitalizations;

11.7.9. Treatment objectives, including discussion of risks and benefits;

11.7.10. Records of drugs prescribed, dispensed, or administered, including the date, type, and dosage;

11.7.11. Treatments;

11.7.12. Receipt and assessment of drug database or prescription monitoring program reports;

11.7.13. Copies of records, reports, or other documentation obtained from other health care practitioners at the request of the physician used for determining appropriate treatment of the patient. Records provided by the patient shall be designated as such; and

11.7.14. A record of all cash transactions.

11.8. All patient records shall be maintained for a minimum of five years from the time that the last documented treatment is provided. In the event a patient is a juvenile, the records shall be kept for a minimum of five years from the time the patient reaches the age of 18 years.

11.9. All patient records shall be kept confidential in accordance with all applicable federal and state requirements.

11.10. Each entry in the medical record shall be completed within 24 hours of the patient contact and shall be dated and signed by the medical staff person involved.

11.11. Information in patient medical records shall be entered only by physicians and other licensed health professionals. Entries shall be legible and organized in an effective manner, allowing materials to be easily retrieved.

W. Va. Code R. § 69-8-11