WAC 246-320-166   Management of information.  The purpose of this section is to improve patient outcomes and hospital performance through obtaining, managing, and using information.

     Hospitals must:

     (1) Provide medical staff, employees and other authorized persons with access to patient information systems, resources, and services;

     (2) Maintain confidentiality, security, and integrity of information;

     (3) Initiate and maintain a medical record for every patient assessed or treated including a process to review records for completeness, accuracy, and timeliness;

     (4) Create medical records that:

     (a) Identify the patient;

     (b) Have clinical data to support the diagnosis, course and results of treatment for the patient;

     (c) Have signed consent documents;

     (d) Promote continuity of care;

     (e) Have accurately written, signed, dated, and timed entries;

     (f) Indicate authentication after the record is transcribed;

     (g) Are promptly filed, accessible, and retained according to RCW 70.41.190 and chapter 5.46 RCW; and

     (h) Include verbal orders that are accepted and transcribed by qualified personnel;

     (5) Establish a systematic method for identifying each medical record, identification of service area, filing, and retrieval of all patient's records; and

     (6) Adopt and implement policies and procedures that address:

     (a) Who has access to and release of confidential medical records according to chapter 70.02 RCW;

     (b) Retention and preservation of medical records according to RCW 70.41.190;

     (c) Transmittal of medical data to ensure continuity of care; and

     (d) Exclusion of clinical evidence from the medical record.



[Statutory Authority: Chapter 70.41 RCW and RCW 43.70.040. 09-07-050, § 246-320-166, filed 3/11/09, effective 4/11/09.]