W. Va. Code R. § 69-9-15

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

Section 69-9-15 - MEDICAL RECORDS AND RETENTION

15.1. A medical record must be maintained for every individual evaluated or treated in the facility.

15.2. The center must employ adequate personnel to ensure prompt completion, filing and retrieval of records.

15.3. Medical records must be accurately written, promptly completed, properly filed and retained.

15.4. The center must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.

15.5. Medical records must be retained in their original or legally reproduced form until the patient reaches 24 years of age.

15.6. The center must have a procedure for ensuring the confidentiality of patient records.

15.6.a. Information from or copies of records may be released only to authorized individuals and the facility must ensure that unauthorized individuals cannot gain access to or alter patient records.

15.6.b. Original medical records must be released by the facility only in accordance with federal or state laws, court orders or subpoenas.

15.7. All patient medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with policies and procedures of the center.

15.8. The clinical or medical record must contain, at a minimum, the following:

15.8.a. Biographical information;

15.8.b. Copies of the custody and/or guardianship records;

15.8.c. Court ordered restrictions for the patient;

15.8.d. Reason for the referral;

15.8.e. Admission intake forms;

15.8.f. Discharge plan;

15.8.g. Aftercare plan for ongoing and future service needs;

15.8.h. Psychological, medical, toxicological, diagnostic and psychosocial evaluations;

15.8.i. Assessment information;

15.8.J. Plan of care, including goals of service;

15.8.k. Reports from outside and contracted providers of service to the patient;

15.8.l. Copies of all signed, written consent forms;

15.8.m. Routine documentation of ongoing services;

15.8.n. Documentation of incidents;

15.8.o. Documentation of medication administration records;

15.8.p. Documentation of treatment administration records;

15.8.q. Copies of all written orders for medications or special treatment procedures; and

15.8.r. Closing summary of discharge.

15.9. Medical records shall be maintained, handled and stored in a confidential manner to comply with all state and federal laws.

15.10. Access to the medical record is limited to the:

15.10.a. Patient;

15.10.b. His or her parents, as legally appropriate;

15.10.c. Legal representative;

15.10.d. Attorney, as legally appropriate;

15.10.e. Employees, as needed to provide care; and

15.10.f. Others as permitted by state or federal law.

W. Va. Code R. § 69-9-15