048-15 Wyo. Code R. § 15-14

Current through April 27, 2019

Section 15-14 - Medical Records

Medical records shall stress the psychiatric component, history of findings, and the treatment rendered to patients.

(a) Preferably, a Registered Record Administrator (RRA) or Accredited Record Technician (ART) supervises the medical records function. If such a profes-sionally qualified person is not in charge of Medical Records, a qualified RRA or ART on a consultant or part-time basis shall organize the function, train the personnel, and make periodic visits to evaluate the records and the operation.

(b) Disclosure of psychiatric patient records can be made only when:

(i) The patient or guardian consents in writing; or

(ii) The patients parent or guardian consents in writing, if the patient is a minor or incompetent; or

(iii) It is necessary to effect treatment; or

(iv) It is necessary for continuing treatment in the event of transfer or referral to another facility or service; or

(v) It is necessary for a pending court disposition or commitment proceeding.

(c) Records of Psychiatric Hospitals shall be preserved, either in the original form or on microfilm, for a period of time determined by the Psychiatric Hospital Administrator and the Archives, Records Management, and centralized Microfilm Division of the State of Wyoming Archives and Historical Department. If any records are to be destroyed, final legal authority must be granted by the State of Wyoming Archives and Historical Department Records Committee.

(d) A system of identification and filing to ensure the prompt location of a patients medical records shall be maintained.

(i) Indexing shall be current within three (3) months following discharge of the patient.

(e) Medical records shall contain at least the following information:

(i) Identification Data and Legal Status;

(ii) Admitting/Intercurrent Diagnosis;

(iii) Reasons for Admission;

(iv) Social Service Reports;

(v) Neurological Examinations;

(vi) Psychiatric evaluations;

(vii) Medical History;

(viii) Treatment Plans;

(ix) Treatment notes;

(x) Progress notes; and

(xi) Discharge Summary.

048-15 Wyo. Code R. § 15-14