84-12 Medical records

(A) Each member of the medical staff shall conform to the medical information management department policies, including the following:

Medical record contents.

The attending medical staff member shall be ultimately responsible for the preparation of a complete medical record of each patient. The medical record may contain information collected and maintained by members of the medical staff, limited staff, other licensed healthcare professionals, medical students or providers who participate in the care of the patient in an electronic or paper form. This record shall include the following elements as it applies to the patient encounter:
1. Identification and demographic data including the patient's race and ethnicity.
2. The patient's language and communication needs.
3. Emergency care provided to the patient prior to arrival, if any.
4. The legal status of patients receiving mental health services.
5. Evidence of known advance directives.
6. Statement of present complaint.
7. History and physical examination.
8. Any patient generated information.
9. Provisional diagnosis.
10. Documentation of informed consent when required.
11. Any and all orders related to the patient's care.
12. Special reports, as those from:
  1. The clinical laboratory, including examination of tissues and autopsy findings, when applicable.
  2. Signed and dated reports of nuclear medicine interpretations, consultations, and procedures.
  3. The radiology department.
  4. Consultants.
13. Medical and surgical treatments.
14. Progress notes.
15. Pre-sedation or pre-anesthesia assessment and plans of care for patients receiving anesthesia.
16. An intra-operative anesthesia record.
17. Postoperative documentation records, including the patient's vital signs and level of consciousness; medications, including IV fluids, blood and blood components; any unusual events or postoperative complications; and management of such events.
18. Postoperative documentation of the patient's discharge from the post-sedation or post-anesthesia care area by the responsible licensed independent practitioner or according to discharge criteria.
19. A post-anesthesia follow-up report written within forty-eight hours after surgery.
20. Reassessments and revisions of the treatment plan.
21. Every dose of medication administered and any adverse drug reaction.
22. Every medication dispensed to an inpatient at discharge.
23. Summary and final diagnosis as verified by the attending medical staff member's signature.
24. Discharge disposition, condition of patient at discharge, and instructions given at that time and the plan for follow up care.
25. Any referrals and communications made to external or internal providers and to community agencies.
26. Any records of communication with the patient made by telephone or email or patient electronic portal.
Deadlines and sanctions.
1. A procedure note shall be entered in the record by the responsible attending medical staff member or the medical staff member's designee, who is appropriately credentialed by the hospital, immediately upon completion of an invasive procedure. Procedure notes must be written for any surgical or medical procedures, irrespective of their repetitive nature, which involve material risk to the patient. Notes for procedures completed in the operating rooms must be finalized in the operating room information system by the attending surgeon. For any formal operative procedures, a note shall include preoperative and postoperative diagnoses, procedure(s) performed and description of each procedure, surgeon(s), resident(s), anesthesiologist(s), surgical service, type of anesthesia (general or local), complications, estimated blood loss, any pertinent information not included on the O.R./anesthesia record, preliminary surgical findings, and specimens removed and disposition of each specimen. Where a formal operative report is appropriate, the report must be completed immediately following the procedure. The operative/procedure report must be signed by the attending medical staff member. Any operative/procedure report not completed or any procedure note for procedures completed in the operating rooms not completed in the operating room information system by ten a.m. the day following the procedure shall be deemed delinquent and the attending medical staff member responsible shall lose operating/procedure room and medical staff privileges the following day. The operating rooms and procedure rooms will not cancel cases scheduled before the suspension occurred.
  
  Effective with the suspension, the attending medical staff member will lose all privileges to schedule elective and add-on cases. The attending medical staff member will only be allowed to schedule emergency cases until all delinquent operative/procedure reports are completed. All emergency cases scheduled by suspended medical staff members are subject to the review of the medical director and will be reported to the suspended medical staff members' chief of the clinical department and the medical director by the operating room staff. Affected medical staff members shall receive telephone calls from the medical information management department indicating the delinquent operative/procedure reports.
2. Progress notes must provide a pertinent chronological report of the patient's course in the hospital and reflect any change in condition, or results of treatment. In the event that the patient's condition has not changed, and no diagnostic studies have been done, a progress note must be completed by the attending medical staff member or his or her designated member of the limited medical staff or practitioner with appropriate privileges at least once every day.
  
  Each medical student or other licensed health care professional progress note in the medical records should be signed or counter-signed by a member of the attending, courtesy, or limited staff.
3. Medical staff members with more than twenty-five verbal orders that remain unsigned greater than twenty-one days after the date of order will be subject to corrective action including administrative suspension which may include suspension of admitting and operating room scheduling privileges until the orders are signed. Medical staff members shall be notified electronically prior to suspension for unsigned verbal orders.
4. Birth certificates must be signed by the medical staff member who delivers the baby within one week of completion of the certificate. Fetal death certificates and death certificates must be signed and the cause of death must be recorded by the medical staff member with a permanent Ohio license within twenty-four hours of death.
5. Office visit encounters shall be closed within ten days of the patient's visit.
6. All entries not previously defined must be signed within ten days of completion.
7. Queries by clinical documentation specialists requesting clarification of a patient's diagnoses and procedures will be resolved within five business days of confirmed notification of request.
Discharges.
1. Patients may not be discharged without a written or electronically entered discharge order from the appropriately credentialed, responsible medical staff member, limited staff member, or other licensed healthcare professional.
2. At the time of discharge, the appropriately credentialed attending medical staff member, limited staff member, or other licensed healthcare professional is responsible for verifying the principal diagnosis, secondary diagnoses, the principal procedure, if any, and any other significant invasive procedures that were performed during the hospitalization. If a principal diagnosis has not yet been determined, then a "provisional" principal diagnosis should be used instead.
3. The discharge summary must be available to any facility receiving the patient before the patient arrives at the facility. Similarly, the discharge summary must be available to the care provider before the patient arrives at any outpatient care visit subsequent to discharge. The discharge summary should be available within forty-eight hours of discharge for all patients. The discharge summary should be signed by the responsible medical staff member within forty-eight hours of availability.
4. The discharge summary must contain the following elements:
  1. hospital course including reason for hospitalization and significant findings upon admission;
  2. principal and secondary diagnoses or provisional diagnoses;
  3. relevant diagnostic test results;
  4. procedures performed and care, treatment and services provided;
  5. condition at discharge;
  6. medication list and medication instructions;
  7. plan for follow up of tests and studies for which results are pending at discharge;
  8. coordination and planning for follow-up testing and appointments;
  9. plans for follow up care and communication, and the instructions provided to the patient.
5. A complete summary is required on all patients who expire, regardless of length of stay.
6. All medical records must be completed by the attending medical staff member or, when applicable, the limited staff member or other licensed healthcare professional within twenty-one days of discharge of the patient.
7. Attending medical staff members shall be notified prior to suspension for all incomplete records. After notification, attending medical staff members shall have their admitting and operative scheduling privileges suspended until all records are completed. Attending medical staff members shall receive electronic notification of delinquent records. If an attempt is made by the attending medical staff member, or the attending medical staff member's designee, who is appropriately credentialed by the hospital, when applicable, to complete the record, and the record is not available, electronically for completion, the record shall not be counted against the attending medical staff member. Medical staff members who are suspended for a period of longer than one hundred twenty consecutive days are required to appear before the practitioner evaluation committee.
8. Records which are incomplete, more than twenty-one days after discharge or the patient’s visit are defined as delinquent.
Confidentiality.

Access to medical records is limited to use in the treatment of patients, research, and teaching. All medical staff members are required to maintain the confidentiality of medical records. Improper use or disclosure of patient information is subject to disciplinary action.
Ownership.

Medical records of hospital-sponsored care including pathological examinations, slides, radiological films, photographic records, cardiographic records, laboratory reports, statistical evaluations, etc. are the property of the hospital and shall not be removed from the hospital's jurisdiction and safekeeping except in accordance with a court order, subpoena, or statute.
Records storage and security.

In general, medical records shall be maintained by the hospital. Records on microfilms, paper, electronic tape recordings, magnetic media, optical disks, and such other acceptable storage techniques shall be used to maintain patient records for twenty-one years for minors and ten years for adults. In the case of readmission of the patient, all records or copies thereof from the past ten/twenty-one years shall be available for the use of the attending medical staff member or other health care providers.
Informed consent documentation.
1. Where informed consent is required for a special procedure (such as surgical operation), documentation that such consent has been obtained must be made in the hospital record prior to the initiation of the procedure. Such documentation shall be incompliance with the hospitals policy and procedure manual section 03-27.
2. In the case of limb amputation, a limb disposition form, in duplicate, must be signed prior to the operation.
Sterilization consent.

Prior to the performance of an operative procedure for the expressed purpose of sterilization of a (male or female) patient, the attending medical staff member shall be responsible for the completion of the legal forms provided by the hospital and signed by the patient. Patients who are enrolled in the Medicaid program must have their forms signed at least thirty days prior to the procedure. Informed consent must also be obtained from one of the parents or the guardian of an unmarried minor.
Criteria changes.

The medical information management department shall define the criteria for record completion subject to the approval of the medical staff.
Entries and authentication.
1. Entries in the medical record can only be made by staff recommended by the medical information management department subject to the approval of the medical staff.
2. All entries must be legible and complete and must be authenticated, timed and dated promptly by the person, identified by name and discipline, who is responsible for ordering, providing, or evaluating the service furnished.
3. The electronic signature of medical record documents requires a signing password. At the time the password is issued, the individual is required to sign a statement that she/he will be the only person using the password. This statement will be maintained in the department responsible for the electronic signature system.
4. Signature stamps may not be used in the medical record.

(Board approval dates: 9/6/2002, 3/5/2003, 6/4/2004, 5/6/2005, 11/4/2005, 2/2/2007, 11/2/2007, 6/6/2008, 9/18/2009, 4/8/2011, 8/31/2012, 4/6/2016, 9/2/2016, 4/6/2018, 5/31/2019, 2/8/2022)