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Filing and Retrieval of Hospital Patient Medical Records - 10-144-112 Me. Code R. § XII.D.

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All patient medical records must be readily available and filed in a manner that allows for prompt retrieval.  The record department must be supervised by a registered records administrator or an accredited records technician, and must provide an orientation program for new employees of the department.  Additionally, the department must have a quality assurance plan in place to continually monitor and evaluate the services that are provided, and implement improvements if needed.  A backup plan must exist that permits the retrieval of records by appropriately trained personnel when it is not possible to staff the records department 24 hours a day, 7 days a week.  Finally, the hospital must use a coding system for diseases and procedures in order to maintain an indexing system that allows for easy retrieval of statistical and billing information.

 


Current as of June 2015