3701-84-11 General medical records requirements.

(A) The 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) The 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, including but not limited to the provisions of this chapter of the Administrative Code.

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

(E) The 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.

Effective: 06/21/2012
R.C. 119.032 review dates: 04/05/2012 and 05/01/2017
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