The purpose of this section is to improve patient outcomes and ambulatory surgical facility performance through obtaining, managing, and use of information.

An ambulatory surgical facility must:

1. (1) Provide medical staff, employees and other authorized persons with access to patient information systems, resources, and services;
2. (2) Maintain confidentiality, security, and integrity of information;
3. (3) Initiate and maintain a medical record for every patient assessed or treated including a process to review records for completeness, accuracy, and timeliness;

4. (4) Create medical records that:

   1. (a) Identify the patient;
   2. (b) Have clinical data to support the diagnosis, course and results of treatment for the patient;
   3. (c) Have signed consent documents;
   4. (d) Promote continuity of care;
   5. (e) Have accurately written, signed, dated, and timed entries;
   6. (f) Indicates authentication after the record is transcribed;
   7. (g) Are promptly filed, accessible, and retained according to facility policy; and
   8. (h) Include verbal orders that are accepted and transcribed by qualified personnel.
5. (5) Establish a systematic method for identifying each medical record, identification of service area, filing, and retrieval of all patient's records; and

6. (6) Adopt and implement policies and procedures that address:

   1. (a) Who has access to and release of confidential medical records according to chapter 70.02 RCW;
   2. (b) Retention and preservation of medical records;
   3. (c) Transmittal of medical data to ensure continuity of care; and
   4. (d) Exclusion of clinical evidence from the medical record.

[Statutory Authority: Chapter 70.230 RCW. WSR 09-09-032, § 246-330-150, filed 4/7/09, effective 5/8/09.]