Section 124.14. Medical record services.

 

(1)   Medical record. A medical record shall be maintained for every patient admitted for care in the hospital. The record shall be kept confidential and released only in accordance with ss. 51.30 , 146.81 to 146.83 , or 252.15 , Stats., and ch. DHS 92 , as appropriate.

(2)   Service.

(a) General requirement. The hospital shall have a medical records service with administrative responsibility for all medical records maintained by the hospital.

(b) Confidentiality.

1. Written consent of the patient or the patient's legally authorized representative shall be presented as authority for release of medical information to persons not otherwise authorized to receive this information.

2. Original medical records may not be removed from the hospital except by authorized persons who are acting in accordance with a court order, a subpoena issued under s. 908.03 (6m) , Stats., or in accordance with contracted services, and where measures are taken to protect the record from loss, defacement, tampering and unauthorized access.

(c) Preservation. There shall be a written policy for the preservation of medical records, either the original record or in the form of microfiche. The retention period shall be determined by each hospital based on historical research, legal, teaching, and patient care needs but medical records shall be maintained for at least 5 years.

(d) Personnel.

1. Adequate numbers of personnel who are qualified to supervise and operate the service shall be provided.

2.

a. A registered medical records administrator or an accredited records technician shall head the service, except that if such a professionally qualified person is not in charge of medical records, a consultant who is a registered records administrator or an accredited records technician shall organize the service, train the medical records personnel and make periodic visits to the hospital to evaluate the records and the operation of the service.

b. In this subdivision, "registered medical records administrator" means a person who has graduated from a 4-year college or university or from a one-year post-graduate certificate program in medical records administration and who meets the standards for registration as a medical records administrator of the American medical record association, and "accredited records technician" means a person who is a graduate of an independent study program or an associate degree program in medical records technology and meets the standards for accreditation as a medical records technician of the American medical record association.

(e) Availability.

1. The system for identifying and filing records shall permit prompt location of each patient's medical records.

2. A master patient index shall include at least the patient's full name, sex, birthdate and medical record number.

3. Filing equipment and space shall be adequate to maintain the records and facilitate retrieval.

4. The inpatient, ambulatory care and emergency records of a patient shall be kept in such a way that all information can be assembled routinely when the patient is admitted to the hospital, when the patient appears for a pre-scheduled ambulatory care visit, or as needed for emergency services.

5. Pertinent medical record information obtained from other providers shall be available to facilitate continuity of the patient's care.

6. The original or a legally reproduced copy of all documents containing clinical information pertaining to a patient's stay shall be filed in the medical record.

(f) Coding and indexing.

1. Records shall be coded and indexed according to disease, operation and physician. Indexing shall be kept up-to-date.

2. Any recognized system may be used for coding diseases and operations.

3. The indices shall list the specific diseases for which the patient was treated during the hospitalization and the operations and procedures which were performed during the hospitalization.

(3)   Responsibilities.

(a) Medical record contents. The medical record staff shall ensure that each patient's medical record contains:

1. Accurate patient identification data;

2. A concise statement of complaints, including the chief complaint which led the patient to seek medical care and the date of onset and duration of each;

3. A health history, containing a description of present illness, past history of illness and pertinent family and social history;

4. A statement about the results of the physical examination, including all positive and negative findings resulting from an inventory of systems;

5. The provisional diagnosis;

6. All diagnostic and therapeutic orders;

7. All clinical laboratory, x-ray reports and other diagnostic reports;

8. Consultation reports containing a written opinion by the consultant that reflects, when appropriate, an actual examination of the patient and the patient's medical record;

9. Except in an emergency, an appropriate history and physical work-up recorded in the medical record of every patient before surgery;

10. An operative report describing techniques and findings written or dictated immediately following surgery and signed by the surgeon;

11. Tissue reports, including a report of microscopic findings if hospital regulations require that microscopic examination be done. If only macroscopic examination is warranted, a statement that the tissue has been received and a macroscopic description of the findings provided by the laboratory shall be filed in the medical record;

12. Physician notes and non-physician notes providing a chronological picture of the patient's progress which are sufficient to delineate the course and the results of treatment;

13. A definitive final diagnosis expressed in the terminology of a recognized system of disease nomenclature;

14. A discharge summary including the final diagnosis, the reason for hospitalization, the significant findings, the procedures performed, the condition of the patient on discharge and any specific instructions given the patient or family or both the patient and the family;

15. Autopsy findings when an autopsy is performed; and

16. Anatomical gift information obtained under s. DHS 124.05 (3) (i) . Documentation shall include the name and title of the person who requests the anatomical gift, the name of the patient's agent as defined in s. 157.06 (2) (a) , Stats., the response to the request for an anatomical gift and, if a determination is made that a request should not be made, the basis for that determination. This information shall be recorded promptly in the medical record where it shall be prominently set out.

(b) Authentication. Only members of the medical staff or other professional personnel authorized by the medical staff shall record and authenticate entries in the medical record. In hospitals with house staff, documentation of medical staff participation in the care of the patient shall be evidenced by at least:

1. The attending physician's countersignature on the patient's health history and results of his or her physical examination;

2. Periodic progress notes or countersignatures as defined by the medical staff rules;

3. The surgeon's signature on the operative report; and

4. The attending physician's signature on the face sheet and discharge summary.

(c) Completion.

1. Current records and those on discharged patients shall be completed promptly.

2. If a patient is readmitted within 30 days for the same or a related condition, there shall be a reference to the previous history with an interval note, and any pertinent changes in physical findings shall be recorded.

3. All records of discharged patients shall be completed within a reasonable period of time specified in the medical staff by-laws, but not to exceed 30 days.

(4)   Maternity patient and newborn records.

(a) Prenatal findings. Except in an emergency, before a maternity patient may be admitted to a hospital, the patient's attending physician shall submit a legible copy of the prenatal history to the hospital's obstetrical staff. The prenatal history shall note complications, Rh determination and other matters essential to adequate care.

(b) Maternal medical record. Each obstetric patient shall have a complete hospital record which shall include:

1. Prenatal history and findings;

2. The labor and delivery record, including anesthesia;

3. The physician's progress record;

4. The physician's order sheet;

5. A medicine and treatment sheet, including nurses' notes;

6. Any laboratory and x-ray reports;

7. Any medical consultant's notes; and

8. An estimate of blood loss.

(c) Newborn medical record. Each newborn infant shall have a complete hospital record which shall include:

1. A record of pertinent maternal data, type of labor and delivery, and the condition of the infant at birth;

2. A record of physical examinations;

3. A progress sheet recording medicines and treatments, weights, feedings and temperatures; and

4. The notes of any medical consultant.

(d) Fetal death. In the case of a fetal death, the weight and length of the fetus shall be recorded on the delivery record.

(5)   Authentication of all entries.

(a) Documentation.

1. All entries in medical records by medical staff or other hospital staff shall be legible, permanently recorded, dated and authenticated with the name and title of the person making the entry.

2. A rubber stamp reproduction of a person's signature may be used instead of a handwritten signature, if:

a. The stamp is used only by the person whose signature the stamp replicates; and

b. The facility possesses a statement, signed by the person, certifying that only that person is authorized to possess and use the stamp.

(b) Symbols and abbreviations. Symbols and abbreviations may be used in medical records if approved by a written facility policy which defines the symbols and abbreviations and controls their use.

Cr. Register, January, 1988, No. 385 , eff. 2-1-88; am. (3) (a) 14. and 15., cr. (3) (a) 16., Register, November, 1993, No. 455 , eff. 12-1-93; correction in (1) made under s. 13.93 (2m) (b) 7., Stats., Register, August, 1995, No. 476 ; correction in (1) made under s. 13.93 (2m) (b) 7., Stats., Register July 2001 No. 547 ; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637 ; CR 10-091 : am. (3) (a) 16. Register December 2010 No. 660 , eff. 1-1-11.