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La. Admin. Code tit. 48, pt. I, § 9387

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Organization and Staffing

Hospitals must have a medical records department responsible for maintain medical records for each person evaluated as an inpatient, outpatient or emergency patient.   Medical records maintained off-site must be unified into a record system of the provider.  Medical records must be kept under the supervision of a medical record administrator on a full time, part time of consulting basis. 

Medical records must be legible and accurate and be signed and dated by the recording person.  If the medical record is electronic, it must be authenticated, complete, properly filed and accessible.  If fax transmission is used, thermal paper should be used to ensure that a legible copy is retained as long as the medical record is kept. 

All medications and treatments must be made pursuant to signed, written orders.  There must be a reliable way to personally identify each patient.  The hospital bylaws must include procedures for dealing with verbal or electronic orders, and must require that signatures for the orders be provided within 10 days.  Signature stamps may be used as long as there is one designated person who will use it.  If an electronic signature is used, there must be a mechanism to ensure the confidentiality of the signature and to ensure the signature is not used improperly.  The hospital must ensure there are enough medical record personnel to retrieve, file and complete medical records. 

The hospital must have a system of coding and filing medical records that allows timely retrieval by diagnosis to support quality improvement assessments.  All medical records must be completed within 30 days from discharge. 

A patient or patient’s representative must be given reasonable access to information contained in the medical record.  The hospital must furnish copies of the medical record as soon as practicable not to exceed 15 days from the written request by the patient, written authorization and payment of reasonable copying fees.  A hospital may deny access to the medical record if a licensed health care practitioner determines access will likely endanger the safety of the patient or other person.  A hospital record may be maintained in a written, photographic, microfilm, or be kept in a data compilation that is approved by the Department against alteration.  A hospital may use microfilm or reproduce records to more efficiently preserve medical records. 

Related Law: LSA –R.S. 40:2144

Current as of June 2015