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N.D. ADMIN. CODE § 33-07-01.1-20 - Medical records services under the State Department of Health regulations

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A hospital must retain patient records for 10 years from the date a patient was last treated. In the case of minors, records must be retained until the patient turns 21 years old or 10 years from the date the patient was last treated, whichever is later.
Medical records must be confidential. Only authorized personnel shall have access. Written consent is required for release of medical information. Records only be removed pursuant to subpoena or court order.
Records should be preserved in original form or via microfilm or similar method. A hospital may not destroy records that are involved in litigation that has not been finally resolved.
A registered record administrator, accredited record technician, consultant registered record administrator, or accredited record technician shall be in charge of medical records, train personnel, and make at least quarterly visits to the hospital to evaluate the service.
A system of identification must exist that allows prompt location of a patient’s record. Records must be organized by disease, operation, and practitioner. Indexing must be current within six months following discharge.
Records must include the following:
·         Patient identification data
·         Chief complaint
·         Present illness
·         Past history
·         Family history
·         Physical examination
·         Provisional diagnosis
·         Treatment
·         Progress notes
·         Final diagnosis
·         Discharge summary
·         Nurses’ notes
·         Laboratory, x-ray, consultation, surgical, tissue and applicable autopsy reports
All entries must be authenticated by the author. Records must be completed promptly upon discharge.

Current as of January 2016