PURPOSE: This rule establishes minimum requirements for medical records kept in hospitals.

1. (1) The director of the medical record services shall be appointed by the chief executive officer or chief operating officer. This director may be a qualified registered record SENIOR SERVICES

administrator, an accredited record technician or an individual with demonstrated competence and knowledge of medical record department activities supervised by a qualified consultant who is a registered record administrator or accredited record technician.

1. (2) Patient care by members of the medical staff, nursing staff and allied health professionals shall be entered in the patient’s medical record in a timely manner. Documentation shall be legible, dated, authenticated and recorded in ink, typewritten or recorded electronically.
2. (3) All orders shall be dated and authenticated by the ordering practitioner and shall be kept in the patient’s medical record. Verbal orders shall be authenticated by the prescribing practitioner or attending physician within the time frame that is defined by the medical staff in cooperation with nursing and administration. Authentication shall include written signatures, initials, computer-generated signature codes or rubber stamp signatures by the medical members and authorized persons whose signatures the stamp represents. The use of rubber stamps is discouraged, but where authorized, a signed statement shall be maintained in the administrative offices with a copy in the medical records department stating that the medical staff member whose stamp is involved is the only one who has the stamp and is the only one authorized to use it. The duplication of signature stamps and the delegation of their use by others is prohibited.
3. (4) Only abbreviations and symbols approved by the medical staff may be used in the medical records. Each abbreviation or symbol shall have only one (1) meaning and an explanatory legend shall be available for use by all concerned. There shall be a list of abbreviations and symbols that shall not be used in handwritten communications.
4. (5) The medical record of each patient shall be maintained in order to justify admission and continued hospitalization, support the diagnosis, describe the patient’s progress and response to medications and services and to facilitate rapid retrieval and utilization by authorized personnel.
5. (6) Medical records are the property of the hospital and shall not be removed from the hospital premises except by court order, subpoena, for the purposes of microfilming or for off-site storage approval by the governing body.
6. (7) Written consent of the patient or the patient’s legal representative is required for access to or release of information, copies or excerpts from the medical record to persons not otherwise authorized to receive this information.
7. (8) Patient records shall be considered complete for filing when the required contents are assembled and authenticated. Hospital policy shall define circumstances in which incomplete medical records may be filed permanently by order of the medical record committee.
8. (9) An inpatient’s medical record shall include: a unique identifying record number; pertinent identifying and personal data; history of present illness or complaint; if injury, how the injury occurred; past history; family history; physical examination; admitting diagnosis; medical staff orders; progress notes; nurses’ notes; discharge summary; final diagnosis; and evidence of informed consent. Where applicable, medical records shall contain reports such as clinical laboratory, X-ray, consultation, electrocardiogram, surgical procedures, therapy, anesthesia, pathology, autopsy and any other reports pertinent to the patient’s care.
9. (10) Admission forms shall be designed to record pertinent identifying and personal data.
10. (11) A certificate of live birth shall be prepared for each child born alive and shall be forwarded to the local registrar within seven
11. (7) days after the date of delivery. If the physician or other person in attendance does not certify to the facts of birth within five (5) days after the birth, the person in charge of the institution shall complete and sign the certificate.
12. (12) When a dead fetus is delivered in an institution, the person in charge of the institution or his/her designated representative shall prepare and, within seven (7) days after delivery, file a report of fetal death with the local registrar.
13. (13) Medical records of deceased patients shall contain the date and time of death, autopsy permit, if granted, disposition of the body, by whom received and when.
14. (14) The State Anatomical Board shall be notified of an unclaimed dead body. A record of this notification shall be maintained.
15. (15) The patient’s medical records shall be maintained to safeguard against loss, defacement and tampering and to prevent damage from fire and water. Medical records shall be preserved in a permanent file in the original, on microfilm or other electronic media. Patients’ medical records shall be retained for a minimum of ten (10) years, except that a minor shall have his/her record retained until his/her twenty-third birthday, whichever occurs later. Preservation of medical records may be extended by the hospital for clinical, educational, statistical or administrative purposes.
16. (16) There shall be a mechanism for the review and evaluation on a regular basis of the quality of medical record services.
17. (17) Should the hospital cease to be licensed, arrangements for disposition of the patient medical records shall be made with nearby hospitals, the patient’s physician or a reliable storage company. Notification of the disposition is to be provided to the department.
18. (18) A history and physical examination shall be completed on each inpatient within twenty-four (24) hours of admission, or a history and physical examination shall have been completed or updated within the seven (7) days prior to admission. A history and physical which is performed up to and no more than thirty (30) days before admission may be utilized provided that the patient is reassessed and an update note is written, signed and dated to reflect the patient’s status within seven (7) days prior to, or within twenty-four
19. (24) hours after, admission.
20. (19) A patient’s records shall be completed within thirty (30) days of discharge.

AUTHORITY: sections 192.006 and 197.080, RSMo 2000 and 197.154, RSMo Supp. 2007.* This rule previously filed as 19 CSR 30-20.021(3)(D). Original rule filed June 27, 2007, effective Feb. 29, 2008.

*Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995; and 197.154, RSMo 2004.