WAC 246-324-200   Clinical records.  (1) The licensee shall establish and maintain an organized clinical record service, consistent with recognized principles of record management, directed, staffed, and equipped to:

     (a) Ensure timely, complete and accurate identification, checking, processing, indexing, filing, and retrieval of records;

     (b) Facilitate compilation, maintenance, analyses, and distribution of patient care statistics; and

     (c) Protect records from undue deterioration and destruction.

     (2) The licensee shall develop and maintain an individual clinical record for each person receiving care, treatment, or diagnostic service at the hospital.

     (3) The licensee shall ensure prompt entry and filing of the following data into the clinical record for each period a patient receives inpatient or outpatient services:

     (a) Identifying information;

     (b) Assessment and diagnostic data including history of findings and treatment provided for the dependency for which the patient is treated in the hospital;

     (c) Comprehensive treatment plan;

     (d) Authenticated orders for:

     (i) Drugs or other therapies;

     (ii) Therapeutic diets; and

     (iii) Care and treatment, including standing medical orders used in the care and treatment of the patient, except standing medical emergency orders;

     (e) Significant observations and events in the patient's clinical treatment;

     (f) Any restraint of the patient;

     (g) Data bases containing patient information;

     (h) Original reports or durable, legible, direct copies of original reports, of all patient tests, diagnostic procedures and examinations performed on or for the patient;

     (i) Description of therapies administered, including drug therapies;

     (j) Nursing services;

     (k) Progress notes recorded by the professional staff responsible for the care of the patient or others significantly involved in active treatment modalities; and

     (l) A discharge plan and discharge summary.

     (4) The licensee shall ensure each entry includes:

     (a) Date;

     (b) Time of day;

     (c) Authentication by the individual making the entry; and

     (d) Diagnosis, abbreviations and terminology consistent with:

     (i) Fourth edition revised 1994 The American Psychiatry Association Diagnostic and Statistical Manual of Mental Disorders; and

     (ii) International Classification of Diseases, 9th edition, 1988.

     (5) The licensee shall provide designated areas, designed to assure confidentiality, for reading, recording, and maintaining patient clinical records and for patients to review their own records.

     (6) The licensee shall prevent access to clinical records by unauthorized persons.    

     (7) The licensee shall retain and preserve:

     (a) Each patient's clinical records, excluding reports on referred outpatient diagnostic services, for:

     (i) Adult patients, a minimum of ten years following the most recent discharge; or

     (ii) Patients who are minors at the time of care, treatment, or diagnosis, a minimum of three years following the patient's eighteenth birth date, or ten years following the most recent discharge, whichever is longer;

     (b) Reports on referred outpatient diagnostic services for at least two years;

     (c) A master patient index card or equivalent for at least the same period of time as the corresponding clinical records; and

     (d) Patients' clinical records, registers, indexes, and analyses of hospital service in original form or in photographic form in accordance with the provisions of chapter 5.46 RCW.



[Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. 95-22-013, § 246-324-200, filed 10/20/95, effective 11/20/95.]