10A NCAC 13D .2401. MAINTENANCE OF MEDICAL RECORDS

(a)  The facility shall establish a medical records service.  It shall be directed, staffed and equipped to ensure:

(1)           records are processed, indexed and filed accurately;

(2)           records are stored in such a manner as to provide protection from loss, damage or unauthorized use;

(3)           records contain sufficient information to identify the patient plus a record of all assessments; plan of care; pre‑admission screening, if applicable; records of implementation of plan of care; progress notes; and record of discharge, including a discharge summary signed by the physician; and

(4)           records are readily accessible by authorized personnel.

(b)  The facility shall ensure that a master patient index is maintained, listing patients alphabetically by name, dates of admission, dates of discharge and case number.

(c)  The administrator shall designate an employee who works full‑time to be the medical records manager.  The manager shall advise, administer, supervise and perform work involved in the development, analysis, maintenance and use of medical records and reports.  If that employee is not qualified by training or experience in medical record science, he or she shall receive consultation from a registered records administrator or an accredited medical record technician to ensure compliance with rules contained in this Subchapter.  The facility shall provide orientation, on‑the‑job training and in‑service programs for all medical records personnel.

 

History Note:        Authority G.S. 131E‑104;

RRC objection due to lack of statutory authority Eff. July 13, 1995;

Eff. January 1, 1996.