1. (1)(a) The licensee shall establish a medical records department or service that is responsible for the administration, custody, and maintenance of medical records.

   1. (b) The hospital administrator shall establish administrative direction of the medical records department and in accordance with the organizational structure and policies of the hospital.
   2. (c) The licensee shall retain the technical services of either a registered health information administrator or a registered health information technician through employment or consultation. If retained by consultation, the individual shall visit at least quarterly and document visits through written reports to the hospital administrator.

2. (2)(a) The licensee shall provide secure storage, controlled access, prompt retrieval, and equipment and facilities to review medical records.

   1. (b) The license shall ensure medical records are available for use or review by:

      1. (i) authorized hospital personnel and agents;
      2. (ii) department representatives to determine compliance with licensing rules;
      3. (iii) members of the medical and professional staff; and
      4. (iv) people authorized by the patient through a consent form.
   2. (c) Medical records may be stored in multiple locations if the record can be retrieved or accessed in a reasonable period.
   3. (d) If computer terminals are utilized for patient charting, the licensee shall have policies governing access and identification codes, security, and information retention.
   4. (e) The licensee shall index a hospital medical record according to diagnosis, procedure, demographic information, and physician or licensed health practitioner and ensure the index is current within six months following discharge of the patient.
   5. (f) Original medical records are the property of the licensee and may not be removed from the control of the licensee or the licensee's agent as defined by policy, except by court order or subpoena.
   6. (g) The licensee shall manage medical records for individuals who have received or requested admission to an alcohol or drug program in accordance with 42 CFR 2.

3. (3)(a) The licensee shall ensure that medical record entries are legible, complete, authenticated, and dated by the person responsible for ordering the service, providing, or evaluating the service, or making the entry. The author shall review prepared transcriptions of dictated reports, evaluations, and consultations before authentication.

   1. (b) The authentication may include written signatures, computer key, or other methods approved by the governing body and medical staff to identify the name and discipline of the person making the entry.
   2. (c) Use of computer key or other methods to identify the author of a medical record entry may not be assignable or delegated to another person.
   3. (d) The licensee shall maintain a current list of individuals approved to use the methods of authentication. Hospital policy shall identify sanctions for the unauthorized or improper use of computer codes.
   4. (e) Qualified personnel shall accept and transcribe verbal orders for the care and treatment of the patient and authenticate them within 30 days of the patient's discharge.

4. (4) The licensee shall ensure:

   1. (a) if a licensee ceases operation, the licensee shall provide secure, safe storage, and prompt retrieval of any medical records, patient indexes, and discharges for the period specified in Subsection (4)(b);
   2. (b) medical records are kept for at least seven years and medical records of minors are kept until the age of 18 plus four years, but in no case less than seven years;
   3. (c) medical records are organized according to hospital policy;
   4. (d) medical records are reviewed at least quarterly for completeness, accuracy, and adherence to hospital policy;
   5. (e) records of discharged patients are collected, assembled, reviewed for completeness, and authenticated within 30 days of the patient's discharge;
   6. (f) the licensee may destroy medical records after keeping them for the minimum period, and before destroying medical records, the licensee shall notify the public by publishing a notice in a newspaper of statewide distribution a minimum of once per week for three consecutive weeks to allow a former patient to access their records; and

   7. (g) The licensee shall permanently keep a master patient or person index that shall include:

      1. (i) the admission and discharge dates;
      2. (ii) the date of birth;
      3. (iii) the medical record number;
      4. (iv) the name of each attending physician; and
      5. (v) the patient name.
5. (5) The licensee may arrange for storage of medical records with another hospital, or an approved medical record storage facility, or may return patient medical records to the attending physician if the physician is still in the community.
6. (6) The licensee shall establish and maintain a complete medical record for each patient admitted, or who receives hospital services. Emergency and outpatient medical records shall contain documentation of the service provided and other pertinent information in accordance with hospital policy.

7. (7) The licensee shall ensure that each medical record contains:

   1. (a) a discharge summary including outcome of hospitalization, disposition of case with an autopsy report when indicated, or provisions for follow-up;
   2. (b) admitting, secondary, and primary diagnoses;
   3. (c) documentation of complications, hospital-acquired infections, and unfavorable reactions to medications, treatments, and anesthesia;
   4. (d) documentation that the facility requested of each admitted person whether the person has initiated an advance health care directive, as described in Title 75A, Chapter 3, Health Care Decisions;

   5. (e)(i) initial or admitting medical history, physical, and other examinations or evaluations; or

      1. (ii) if updated to include changes that reflect the patient's current status, recent histories and examinations;
   6. (f) patient identification and demographic information to include at least the patient's name, address, date of birth, sex, and emergency contact information;
   7. (g) properly executed informed consent documents for any procedures and treatments ordered for, and received by, the patient;

   8. (h) practitioner orders, nursing notes, reports of treatment, medication records, laboratory and radiological reports, vital signs, and other information that documents the patient condition and status; and

      1. (i) results of consultative evaluations and findings by individuals involved in the care of the patient.
8. (8) A medical record of a deceased patient shall contain a completed Inquiry of Anatomical Gift form or a modified hospital death form that has been approved by the department, as required by Title 26B, Chapter 8, Part 3, Revised Uniform Anatomical Gift Act.

9. (9) A medical record of a surgical patient shall contain:

   1. (a) a pre-operative history and physical examination;
   2. (b) an anesthesia report including dosage and duration of any anesthetic and pertinent events during the induction, maintenance, and emergence from anesthesia;
   3. (c) an operative report describing a description of findings;
   4. (d) assistants written or dictated by the surgeon within 24 hours after the operation;
   5. (e) surgeon's diagnosis;
   6. (f) the name of the primary surgeon;
   7. (g) the post-operative diagnosis;

   8. (h) the specimen removed; and

      1. (i) the technical procedures used.

10. (10) A medical record of an obstetrical patient shall contain:

    1. (a) a discharge summary for complicated deliveries or final progress note for uncomplicated deliveries;
    2. (b) a relevant family history;
    3. (c) a serological test for syphilis;
    4. (d) a pre-natal examination;
    5. (e) the anesthesia or analgesia record;
    6. (f) the length of labor and type of delivery with related notes; and
    7. (g) the Rh status and immune globulin administration when indicated.

11. (11) A medical record of a newborn infant shall contain the following documentation in addition to the requirements for obstetrical medical records:

    1. (a) a record of the physical examination completed at birth and discharge, record of ophthalmic prophylaxis, and the identification number of the newborn screening kit;
    2. (b) a summary of the delivery room care;
    3. (c) the gender;
    4. (d) the number, character, and consistency of stools;
    5. (e) the period of gestation;
    6. (f) any reaction after birth;
    7. (g) the temperature and weight;

    8. (h) the authorization by the parents, state agency, or court authority if the infant is discharged to any person other than the infant's parents;

       1. (i) the date and hour of birth;
    9. (j) the record and results of the newborn hearing screening according to Section R398-2-6;

    10. (k) the time of first urination; and

        1. (l)(i) a copy of the parent's delivery room record.
        2. (ii) In an adoption case where the identity of the parent is confidential, the licensee shall include and access the parent's record according to hospital policy.

12. (12) The licensee shall integrate an emergency department patient medical record into the hospital medical record, that includes:

    1. (a) a diagnosis;
    2. (b) disposition and discharge instructions;
    3. (c) emergency care given to the patient before arrival;
    4. (d) history and physical findings;
    5. (e) lab and x-ray reports;
    6. (f) record of treatment; and
    7. (g) time and means of arrival.

13. (13) A medical-social services patient record shall include:

    1. (a) any cooperative activities with community agencies;
    2. (b) a medical-social or psychosocial study of a referred inpatient and outpatient;
    3. (c) an environmental investigation for an attending physician;
    4. (d) social therapy and rehabilitation of the patient; and
    5. (e) the financial status of the patient.

14. (14) A medical record of a patient receiving rehabilitation therapy shall include:

    1. (a) a problem list;
    2. (b) a written plan of care appropriate to the diagnosis and condition; and
    3. (c) short and long term goals.
15. (15) The medical records department shall maintain records, reports, and documentation of admissions, discharges, and the number of autopsies performed.

16. (16)(a) The medical records department shall maintain vital statistic registries for births, deaths, and the number of operations performed.

    1. (b) The medical records department shall report vital statistics data in accordance with Title 26B, Chapter 8, Part I, Vital Statistics.

KEY: health care facilities

Date of Last Change: June 5, 2026

Notice of Continuation: August 22, 2025

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-202; 26B-2-203