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902 KY. ADMIN. REGS. 20:016 - Hospitals; operations and services under the cabinet for health and family services department for public health regulations

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Section 3. (11)
 
Hospital records shall be maintained in accordance with professional standards for all patients.
 
A registered records administrator shall direct the medical record service.
 
Hospitals must maintain medical records for a period for 5 years from the date of discharge or, in the case of a minor, 3 years after the patient reaches adulthood. Patient records are the property of the hospital and must not be taken from the facility except by court order.
 
A hospital shall create a system of identification to ensure timely location of patient records.
 
Records may only be accessed by authorized hospital personnel. Information may only be disclosed as authorized the patient, the patient’s guardian, or the executor of the patient’s estate.
 
Medical records must include the following:
·         Patient identification data
·         Signed consent forms
·         Name and address of next of kin
·         Date od admission
·         Name of attending physician
·         Chief complaint
·         Medical history
·         Examination and test reports
·         Diagnoses
·         Orders
·         Treatment notes
·         Surgical record
·         Patient care plan
·         Progress notes
·         Discharge summary
·         Cause of death
 
The hospital shall maintain an index of records according to disease, operation, and attending physician. Indexing must be current within 6 months following patient discharge.
 


Current as of January 2016