3701-84-11 General medical records requirements.

(A) Each provider of a HCS shall maintain a medical record for each patient that documents, in a timely manner and in accordance with acceptable standards of practice, the patient's needs and assessments, and services rendered. Each medical record shall be legible and readily accessible to staff for use in the ordinary course of treatment.

(B) Each provider of a HCS shall not disclose individual medical records except as authorized by the patient or allowed by state and federal laws and regulations, and the provisions of this chapter .

(C) Each provider of a HCS shall systematically review records for conformance with acceptable standards of practice and the requirements of Chapter 3701-84 of the Administrative Code.

(D) Each provider of a HCS shall maintain an adequate medical record keeping system and take appropriate measures to protect medical records against theft, loss, destruction, and unauthorized use.

(E) Each HCS shall have policies and procedures to ensure the confidentiality of patient medical records.

(F) Each provider of a HCS shall maintain medical records as necessary to verify the information and reports required by statute or regulation for six years from the date of discharge.

Cite as Ohio Admin. Code 3701-84-11

Effective: 8/1/2017
Five Year Review (FYR) Dates: 02/27/2017 and 03/01/2022
Promulgated Under: 119.03
Statutory Authority: 3702.11, 3702.13
Rule Amplifies: 3702.11, 3702.12, 3702.13 , 3702.14, 3702.141, 3702.15, 3702.16, 3702.18, 3702.19, 3702.20
Prior Effective Dates: 3/1/1997, 3/24/03, 6/21/12