| (2) The facility shall have a system of coding and
indexing medical records. The system shall allow for timely retrieval
by diagnosis and procedure, in order to support medical care evaluation
studies.
(3) The facility shall adopt, implement, and enforce
a policy to ensure that the facility complies with Health and Safety
Code, §576.005 (relating to Confidentiality of Records) and Chapter
611, (relating to Mental Health Records).
(4) The medical record shall contain information to
justify admission and continued hospitalization, support the diagnosis,
and describe the patient's progress and response to medications and
services. Medical records shall be accurately written, promptly completed,
properly filed and retained, and accessible.
(5) The facility shall use a system of author identification
and record maintenance that ensures the integrity of the authentication
and protects the security of all entries to the records.
(A) The author of each entry shall be identified and
shall authenticate his or her entry.
(B) Authentication shall include signatures, written
initials, or computer entry.
(C) Use of signature stamps by physicians may be allowed
in facilities when the signature stamp is authorized by the individual
whose signature the stamp represents. The administrative offices of
the facility shall have on file a signed statement to the effect that
he or she is the only one who has the stamp and uses it. Delegation
of use to another individual shall not be acceptable.
(D) A list of computer codes and written signatures
shall be readily available and shall be maintained under adequate
safeguards.
(E) Signatures by facsimile shall be acceptable. If
received on a thermal machine, the facsimile document shall be copied
onto regular paper.
(6) Medical records (reports and printouts) shall be
retained by the facility in their original or legally reproduced form
for a period of at least ten years. Films, scans, and other image
records shall be retained for a period of at least five years. For
retention purposes, medical records that shall be preserved for ten
years include:
(A) identification data;
(B) the medical history of the patient;
(C) evidence of a physical examination and psychiatric
evaluation;
(D) admitting diagnosis;
(E) diagnostic and therapeutic orders;
(F) properly executed informed consent forms for procedures
and treatments specified by the medical staff, or by federal or state
laws if applicable, to require written patient consent;
(G) treatment plans;
(H) clinical observations, including the results of
therapy and treatment, all orders, nursing notes, medication records,
vital signs, and other information necessary to monitor the patient's
condition;
(I) reports of procedures, tests, and their results,
including laboratory, pathology, and radiology reports;
(J) results of all consultative evaluations of the
patient and appropriate findings by clinical and other staff involved
in the care of the patient;
(K) discharge summary with outcome of hospitalization,
disposition of care, and provisions for follow-up care; and
(L) final diagnosis with completion of medical records
within 30 calendar days following discharge.
(7) If a patient was less than 18 years of age at the
time he was last treated, the facility may authorize the disposal
of those medical records relating to the patient on or after the
date of his 20th birthday or on or after the 10th anniversary of the
date on which he was last treated, whichever date is later.
(8) The facility shall not destroy medical records
that relate to any matter that is involved in litigation if the facility
knows the litigation has not been finally resolved.
(9) If a licensed facility should close, the facility
shall notify the department at the time of closure the disposition
of the medical records, including the location of where the medical
records will be stored and the identity and telephone number of the
custodian of the records.
(h) Medical staff.
(1) The medical staff shall be composed of physicians
and may also be composed of podiatrists, dentists and other practitioners
appointed by the governing body.
(A) The medical staff shall periodically conduct appraisals
of its members according to medical staff bylaws.
(B) The medical staff shall examine credentials of
candidates for medical staff membership and make recommendations to
the governing body on the appointment of the candidate.
(2) The medical staff shall be well-organized and accountable
to the governing body for the quality of the medical care provided
to patients.
(A) The medical staff shall be organized in a manner
approved by the governing body.
(B) If the medical staff has an executive committee,
a majority of the members of the committee shall be doctors of medicine
or osteopathy.
(C) Records of medical staff meetings shall be maintained.
(D) The responsibility for organization and conduct
of the medical staff shall be assigned only to an individual physician.
(E) Each medical staff member shall sign a statement
signifying they will abide by medical staff and hospital policies.
(3) The medical staff shall adopt, implement, and enforce
bylaws, rules, and regulations to carry out its responsibilities.
The bylaws shall:
(A) be approved by the governing body;
(B) include a statement of the duties and privileges
of each category of medical staff (e.g., active, courtesy, consultant);
(C) describe the organization of the medical staff;
(D) describe the qualifications to be met by a candidate
in order for the medical staff to recommend that the candidate be
appointed by the governing body; and
(E) include criteria for determining the privileges
to be granted and a procedure for applying the criteria to individuals
requesting privileges.
(i) Mobile, transportable, and relocatable units. If
the facility provides diagnostic procedures or treatments in mobile,
transportable, or relocatable units, the facility shall adopt, implement
and enforce procedures which address the potential emergency needs
for those inpatients who are taken to mobile units on the facility
premises for diagnostic procedures or treatment.
(j) Nurse staffing.
(1) The hospital shall establish a nurse staffing committee
as a standing committee of the hospital. As used in this subsection,
"committee" or "staffing committee" means a nurse staffing committee
established under this paragraph.
(A) The committee shall be composed of:
(i) at least 60% registered nurses who are involved
in direct patient care at least 50% of their work time and selected
by their peers who provide direct care during at least 50% of their
work time;
(ii) members who are representative of the types of
nursing services provided at the hospital; and
(iii) the chief nursing officer of the hospital who
is a voting member.
(B) Participation on the committee by a hospital employee
as a committee member shall be part of the employee's work time and
the hospital shall compensate that member for that time accordingly.
The hospital shall relieve the committee member of other work duties
during committee meetings.
(C) The committee shall meet at least quarterly.
(D) The responsibilities of the committee shall be
to:
(i) develop and recommend to the hospital's governing
body a nurse staffing plan that meets the requirements of paragraph
(2) of this subsection;
(ii) review, assess and respond to staffing concerns
expressed to the committee;
(iii) identify the nurse-sensitive outcome measures
the committee will use to evaluate the effectiveness of the official
nurse services staffing plan;
(iv) evaluate, at least semiannually, the effectiveness
of the official nurse services staffing plan and variations between
the plan and the actual staffing; and
(v) submit to the hospital's governing body, at least
semiannually, a report on nurse staffing and patient care outcomes,
including the committee's evaluation of the effectiveness of the official
nurse services staffing plan and aggregate variations between the
staffing plan and actual staffing.
(2) The hospital shall adopt, implement and enforce
a written official nurse services staffing plan. As used in this subsection,
"patient care unit" means a unit or area of a hospital in which registered
nurses provide patient care.
(A) The official nurse services staffing plan and policies
shall:
Cont'd... |
