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Health Information Management, Colo. Code Regs. § 6-1011-1 (Chap 20 § 7)

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Health Information Management
Requires ambulatory surgical centers to develop systems for collecting, storing, and using health information and to maintain medical records for all admitted patients. Requires centers to hire an administrator to oversee health information collection and storage. Specifies the information that centers must document in medical records (e.g., patient identifying information, diagnoses, laboratory tests, etc.). Requires centers to protect medical records from physical damage, loss, or unauthorized access and to maintain logs of all data entries and deletions. Establishes standards for the retention of medical records (e.g., adults records must be retained for 10 years after the last entry). Requires centers to notify patients prior to destroying medical records. Identifies statistical information that centers must collect for use in the center’s quality management program (e.g., medical complications, number of patients, type of performed procedures, etc.). Specifies the information that nurses must document (e.g., administration of medications, operative notes, etc.) and requires these nursing notes to be entered into the patient’s medical record.