| (4) Chemical hygiene. A hospital that provides laboratory
services shall adopt, implement, and enforce written policies and
procedures to manage, minimize, or eliminate the risks to laboratory
personnel of exposure to potentially hazardous chemicals in the laboratory
which may occur during the normal course of job performance.
(i) Linen and laundry services. The hospital shall
provide sufficient clean linen to ensure the comfort of the patient.
(1) For purposes of this subsection, contaminated linen
is linen which has been soiled with blood or other potentially infectious
materials or may contain sharps. Other potentially infectious materials
means:
(A) the following human body fluids: semen, vaginal
secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial
fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures,
any body fluid that is visibly contaminated with blood, and all body
fluids in situations where it is difficult or impossible to differentiate
between body fluids;
(B) any unfixed tissue or organ (other than intact
skin) from a human (living or dead); and
(C) Human Immunodeficiency Virus (HIV)-containing cell
or tissue cultures, organ cultures, and HIV or Hepatitis B Virus (HBV)-containing
culture medium or other solutions; and blood, organs, or other tissues
from experimental animals infected with HIV or HBV.
(2) The hospital, whether it operates its own laundry
or uses commercial service, shall ensure the following.
(A) Employees of a hospital involved in transporting,
processing, or otherwise handling clean or soiled linen shall be given
initial and follow-up in-service training to ensure a safe product
for patients and to safeguard employees in their work.
(B) Clean linen shall be handled, transported, and
stored by methods that will ensure its cleanliness.
(C) All contaminated linen shall be placed and transported
in bags or containers labeled or color-coded.
(D) Employees who have contact with contaminated linen
shall wear gloves and other appropriate personal protective equipment.
(E) Contaminated linen shall be handled as little as
possible and with a minimum of agitation. Contaminated linen shall
not be sorted or rinsed in patient care areas.
(F) All contaminated linen shall be bagged or put into
carts at the location where it was used.
(i) Bags containing contaminated linen shall be closed
prior to transport to the laundry.
(ii) Whenever contaminated linen is wet and presents
a reasonable likelihood of soak-through of or leakage from the bag
or container, the linen shall be deposited and transported in bags
that prevent leakage of fluids to the exterior.
(iii) All linen placed in chutes shall be bagged.
(iv) If chutes are not used to convey linen to a central
receiving or sorting room, then adequate space shall be allocated
on the various nursing units for holding the bagged contaminated linen.
(G) Linen shall be processed as follows:
(i) If hot water is used, linen shall be washed with
detergent in water with a temperature of at least 71 degrees Centigrade
(160 degrees Fahrenheit) for 25 minutes. Hot water requirements specified
in Table 5 of §133.169(e) of this title (relating to Tables)
shall be met.
(ii) If low-temperature (less than or equal to 70 degrees
Centigrade) (158 degrees Fahrenheit) laundry cycles are used, chemicals
suitable for low-temperature washing at proper use concentration shall
be used.
(iii) Commercial dry cleaning of fabrics soiled with
blood also renders these items free of the risk of pathogen transmission.
(H) Flammable liquids shall not be used to process
laundry, but may be used for equipment maintenance.
(j) Medical record services. The hospital shall have
a medical record service that has administrative responsibility for
medical records. A medical record shall be maintained for every individual
who presents to the hospital for evaluation or treatment.
(1) The organization of the medical record service
shall be appropriate to the scope and complexity of the services performed.
The hospital shall employ or contract with adequate personnel to ensure
prompt completion, filing, and retrieval of records.
(2) The hospital 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 hospital shall adopt, implement, and enforce
a policy to ensure that the hospital complies with HSC, Chapter 241,
Subchapter G (Disclosure of Health Care Information) and Subchapter
E, §241.103 (Preservation of Records) and §241.1031 (relating
to Preservation of Record from Forensic Medical Examination).
(4) The medical record shall contain information to
justify admission and continued hospitalization, support the diagnosis,
reflect significant changes in the patient's condition, 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) If an attending physician issues a DNR order for
a patient under Health and Safety Code, Chapter 166, Subchapter E
(relating to Health Care Facility Do-Not-Resuscitate Orders), that
order shall be entered into the patient medical record as soon as
practicable. In the event a physician revokes a DNR order under Health
and Safety Code, Chapter 166, Subchapter E, that revocation shall
be entered into the patient medical record as soon as practicable.
To the extent this paragraph conflicts with requirements elsewhere
in this subsection, this paragraph prevails.
(6) Medical record entries must be legible, complete,
dated, timed, and authenticated in written or electronic form by the
person responsible for providing or evaluating the service provided,
consistent with hospital policies and procedures.
(7) All orders (except verbal orders) must be dated,
timed, and authenticated the next time the prescriber or another practitioner
who is responsible for the care of the patient and has been credentialed
by the medical staff and granted privileges which are consistent with
the written orders provides care to the patient, assesses the patient,
or documents information in the patient's medical record.
(8) All verbal orders must be dated, timed, and authenticated
within 96 hours by the prescriber or another practitioner who is responsible
for the care of the patient and has been credentialed by the medical
staff and granted privileges which are consistent with the written
orders.
(A) Use of signature stamps by physicians and other
licensed practitioners credentialed by the medical staff may be allowed
in hospitals when the signature stamp is authorized by the individual
whose signature the stamp represents. The administrative offices of
the hospital 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. The use of
a signature stamp by any other person is prohibited.
(B) A list of computer codes and written signatures
shall be readily available and shall be maintained under adequate
safeguards.
(C) Signatures by facsimile shall be acceptable. If
received on a thermal machine, the facsimile document shall be copied
onto regular paper.
(9) Medical records (reports and printouts) shall be
retained by the hospital in their original or legally reproduced form
for a period of at least ten years. A legally reproduced form is a
medical record retained in hard copy, microform (microfilm or microfiche),
or other electronic medium. 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, including a
health history, performed no more than 30 days prior to admission
or within 24 hours after admission. The medical history and physical
examination shall be placed in the patient's medical record within
24 hours after admission;
(D) an updated medical record entry documenting an
examination for any changes in the patient's condition when the medical
history and physical examination are completed within 30 days before
admission. This updated examination shall be completed and documented
in the patient's medical record within 24 hours after admission;
(E) admitting diagnosis;
(F) diagnostic and therapeutic orders;
(G) 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;
Cont'd... |
