10A NCAC 14F .2002. CONTENT OF MEDICAL RECORDS

(a)  The medical record shall contain at least the following information:

(1)           patient identification data;

(2)           medical history and, when applicable, hospital discharge summary;

(3)           graded exercise data, if available;

(4)           resting 12-lead ECG;

(5)           signed physician referral;

(6)           records of blood chemistry analyses;

(7)           signed informed consent to participate in the program;

(8)           progress notes and response to the cardiac rehabilitation care plan;

(9)           all records of each discipline's participation in the patient's cardiac rehabilitation care plan;

(10)         a discharge summary which describes the patient's progress while in the program, reason(s) for discharge, the post-discharge plan, and follow-up as indicated;

(11)         miscellaneous clinical records developed pursuant to the patient's course of treatment.

(b)  In the case of hard copy medical records, the following shall apply:

(1)           the patient's name must be recorded on each page of the record;

(2)           all entries in the records shall be legible and authenticated with a signature, title, and date by the individual making the entry; and

(3)           faxed entries, including orders, are acceptable as long as a hard copy is incorporated in the medical record (note: thermal paper faxes are not acceptable).

(c)  At its option, the program may maintain all or part of its medical records in a form other than hard copy, such as electronic medium.  Entries in such a record shall be authenticated according to program policies and may include authentication measures such as personal computer entry codes or electronic signatures.  However, when requested by the Division or other State officials, the program must be able to produce a hard copy printout of the record.

(d)  Medical record information may be stored, such as when records are thinned or patients are discharged, in a form other than hard copy, but the program must be able to produce a hard copy printout of the record if requested by the Division or other State officials.

 

History Note:        Authority G.S. 131E-169;

Eff. July 1, 2000.