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Medical records services under the Department of Health and Environment regulations - KAN. ADMIN. REGS. § 28-34-9a

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A registered health information administrator or technician as certified by the American health information management association, or someone who meets the equivalent training must direct the hospital medical records service. If the hospital cannot employ a full-time administrator or technician, the hospital shall employ a part-time administrator or technician on a consultant basis.
 
Hospitals must maintain patient records and retain the records for 10 years, or for a year after a patient turns 18, whichever is longer. A summary of each destroyed record must be maintained for at least 25 years, including:
·         The patient’s name, age, and date of birth
·         The name of the patient’s nearest relative
·         Name of the attending physicians
·         Any surgical procedure and date
·         Final diagnosis
 
Each record is confidential, and may be accessed only by authorized individuals, including individuals investigating compliance.
 
Medical records are the property of the hospital, and may not be removed from the hospital except in connection with litigation or authorized by law or court order.
 
Medical records must contain information sufficient to identify the patient, support the diagnosis and treatment, and document the results:
·         Practitioner notes
·         Results of examinations, treatment and procedures; and
·         Diagnoses and necropsy reports
 
All medical record entries must be dated and authenticated by the author. Orders should be authenticated within 72 hours of discharge, or 30 days, whichever occurs first. Records must be completed within 30 days of discharge.
 


Current as of January 2016