1. (1) The REH shall have a medical record service that has administrative responsibility for medical records and maintains the medical records system in accordance with written policies and procedures. Each REH shall also maintain any picture archiving and communications system (PACS) obtained prior to conversion, which provides for the timely and efficient storage, transmission, and retrieval of digital medical images.
2. (2) Each REH shall maintain a register or log of all patients who present to the REH for treatment or services.

3. (3) For each patient receiving health care services, the REH must maintain a record that includes, as applicable:

   1. (a) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient;
   2. (b) Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings;
   3. (c) All orders of physicians or other practitioners, reports of treatments and medications, nursing notes and documentation of complications, and other pertinent information necessary to monitor the patient's progress, such as temperature graphics, progress notes describing the patient's response to treatment; and
   4. (d) Dated signatures of the physician or other health care professional.
   5. (e) All orders, including verbal orders, shall be dated, timed, and authenticated by the ordering practitioner in accordance with hospital policy, but no longer than 30 days after entry.

4. (4) The REH must maintain the confidentiality of record information and provides safeguards against loss, destruction, or unauthorized use.

   1. (a) The REH must have written policies and procedures that govern the use and removal of records from the REH and the conditions for the release of information.
   2. (b) The patient's written consent is required for release of information not required by law.
   3. (c) The records must be retained for at least 7 years from date of last entry, and longer if required by state statute, or if the records may be needed in any pending proceeding.

5. (5) If the REH utilizes an electronic medical records system or other electronic administrative system, which is conformant with applicable CMS rules, then the REH must demonstrate that:

   1. (a) The system's notification capacity is fully operational and the REH uses it in accordance with all state and Federal statutes and regulations applicable to the REH's exchange of patient health information.
   2. (b) The system sends notifications that must include at least patient name, treating practitioner name, and sending institution name.
   3. (c) To the extent permissible under applicable federal and state laws and regulations, and not inconsistent with the patient's expressed privacy preferences, the system sends notifications directly, or through an intermediary that facilitates exchange of health information, at the time of the patient's registration in the REH's ED.
   4. (d) To the extent permissible under applicable federal and state laws and regulations, and not inconsistent with the patient's expressed privacy preferences, the system sends notifications directly, or through an intermediary that facilitates exchange of health information, either immediately, prior to, or at the time the patient's discharge or transfer from the REH's ED.

   5. (e) The REH makes a reasonable effort to ensure that the system sends the notifications to all applicable post-acute care services providers and suppliers, as well as to any of the following practitioners and entities, which need to receive notification of the patient's status for treatment, care coordination, or quality improvement purposes:

      1. 1. The patient's established primary care practitioner;
      2. 2. The patient's established primary care practice group or entity; or
      3. 3. Other practitioner, or other practice group or entity, identified by the patient as the practitioner, or practice group or entity, primarily responsible for their care.
6. (6) The REH shall maintain a plan to transfer all records to another facility in the event the REH ceases operation.

Author: Dana H. Billingsley

Statutory Authority: Code of Ala. 1975, §§22-21-20, et seq.

History: New Rule: Published August 31, 2023; effective October 15, 2023.