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 registered health information administrator, a health information technician, or an individual with demonstrated competence and knowledge of medical record department activities supervised by a qualified consultant who is a registered health information administrator or health information technician.
2. (2) All patient care documentation shall be entered in the patient’s medical record promptly. Such documentation shall be legible, dated, timed, authenticated, and recorded.
3. (3) All orders, including verbal orders, shall be dated, timed, and authenticated according to hospital policy, but no later than thirty (30) days, by the ordering practitioner or another practitioner who is responsible for the care of the patient and authorized to write orders by hospital policy and shall be kept in the patient’s medical record. Authentication shall consist of written signatures, initials, or computer-generated signature codes.
4. (4) The hospital shall have a written policy that includes abbreviations, acronyms, symbols, and dose designations approved by the medical staff for use in the hospitals and those prohibited from use in the hospital. The prohibited list applies to all orders, preprinted forms and medication related documentation.
5. (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.
6. (6) Medical records are the property of the hospital and shall not be removed from the hospital except by court order, subpoena, or for off-site storage approved by the governing body.
7. (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.
8. (8) Patient records shall be considered complete when the required contents are assembled and authenticated. Hospital policy shall define circumstances in which incomplete medical records may be closed.

9. (9) All medical records shall include, as appropriate:

   1. (A) A medical history and physical examination completed and authenticated no more than thirty (30) days before or twenty-four

10. (24) hours after admissions or registration, but prior to surgery or a procedure requiring anesthesia services, except in the case of emergencies. The medical history and physical examination shall be placed in the patient’s medical record within twenty-four (24) hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, except in the case of emergencies.

    1. (B) An updated examination of the patient, including any changes in the patient’s condition, when the medical history and physical examination are completed within thirty (30) days before admission or registration. Documentation of the updated examination shall be placed in the patient’s medical record within twenty-four (24) hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, except in the case of emergencies;
    2. (C) Admitting diagnosis;
    3. (D) Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient;
    4. (E) Documentation of complications, healthcare-associated infections, and unfavorable reactions to drugs and anesthesia;
    5. (F) Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by federal or state law if applicable, requiring written patient consent;
    6. (G) All practitioners’ orders, nursing notes, reports of treatment, medication records, radiology, laboratory reports, vital signs, and other information necessary to monitor the patient’s condition;
    7. (H) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care; and
    8. (I) Final diagnosis with completion of medical records within thirty (30) days following discharge.
11. (10) A certificate of live birth shall be prepared for each child born alive and shall be forwarded to the local registrar, or as otherwise directed by the state registrar within five
12. (5) 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.
13. (11) 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 or as otherwise directed by the state registrar.
14. (12) Medical records of deceased patients shall contain the date and time of death, 19 CSR 30-20

autopsy permit, if granted, disposition of the body, by whom received and when.

1. (13) The State Anatomical Board shall be notified of an unclaimed dead body. A record of this notification shall be maintained.
2. (14) The patient’s medical records shall be maintained to safeguard against loss, defacement, unauthorized access, 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 twentieth birthday, whichever occurs later. Preservation of medical records may be extended by the hospital for clinical, educational, statistical, or administrative purposes.
3. (15) There shall be a process for the review and evaluation on a regular basis of the quality of medical record services.
4. (16) 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 of Health and Senior Services.

AUTHORITY: section 192.006, RSMo 2000, and sections 197.080 and 197.154, RSMo Supp. 2013.* This rule previously filed as 19 CSR 30-20.021(3)(D). Original rule filed June 27, 2007, effective Feb. 29, 2008. Amended: Filed Dec. 31, 2013, effective Aug. 30, 2014.

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