Costos

SR.1 Administrative responsibility for medical records shall rest with the medical record service of the hospital.

SR.2 The hospital shall provide these services in accordance with the scope and complexities of services offered and allocate the appropriate resources to ensure efficient functioning.

MR.2 – Complete Medical Record

SR.1 The hospital shall maintain an accurately written, promptly completed medical record for each inpatient and outpatient.

SR.2 The hospital shall have a process for providing services for the completion, filing, and retrieval of the medical record. The process for completion of the medical record shall address timeframes.

SR.3 There is a process in place to verify the authenticity of all record entries.

MR.3 – Retention

SR.1 Medical records (original or legally reproduced form) shall be retained for a period of at least five (5) years, or more if required by National or local law.

SR.2 The coding and indexing system should allow for timely retrieval by diagnosis and procedure, in order to support clinical audit.

MR.4 – Confidentiality

SR.1 Confidentiality of medical records shall be assured.

SR.2 Individuals who are authorized by the patient to receive information from or copies of records shall follow the local and national guidance on confidentiality.

SR.3 The hospital shall also ensure that the medical record cannot be altered or accessed by unauthorized individuals.

SR.4 Original medical records shall be released by the hospital only in accordance with National or local law, court orders, or subpoenas.

MR.5 – Record Content

SR.1 The medical record shall contain information to: a) justify admission and continued hospitalization; b) support the diagnosis; and

c) describe the patient’s progress and response to medications and services.

SR.2 All entries shall be:

a) legible, complete, dated and timed; and

b) authenticated by the person responsible for providing patient care in accordance with hospital policy.

SR.3 Authentication may include written signatures. Electronic authentication is permissible.

SR.4 All orders shall be dated, timed and authenticated promptly by the prescribing practitioner. a) Practitioners shall separately date and time his/her signature, authenticating an entry, even

though there may already be a date and time on the document, since the document may not reflect when the entry was authenticated;

b) If a preprinted order set is used, the ordering practitioner shall date, time, and authenticate the last page of the order set, with the last page also identifying the total number of pages in the order set; and

Sec.24 - Page 43

DNV Standard for Hospitals, DNV-DS-HC101 December 2011, Version 2.0

c) Changes, such as additions, deletions, or strike-outs of components that do not apply, that have been made in the body of the preprinted order set are initialed and all internal pages have been signed or initialed by the ordering practitioner.

SR.5 Verbal orders shall be authenticated within forty eight (48) hours.

a) Telephone or verbal orders are to be used infrequently and when used shall be accepted only by personnel authorized by the medical staff.

b) Verbal orders shall be authenticated by the ordering practitioner or a practitioner responsible for the care of the patient. If there is not National or local law that designates a specific timeframe for the authentication of verbal orders, the orders shall be authenticated within 48 hours.

c) For the limited time period defined all such orders may be dated, timed and authenticated by another practitioner who is responsible for the patient’s care and who is authorized to write orders in accordance with hospital policy and National or local law.

MR.6 – Identification of Authors

The hospital shall have a system to identify the author of each entry within the medical record.

MR.7 – Required Documentation

All records shall document the following, as appropriate:

SR.1 Evidence of a physical examination, including a health history, performed no more than thirty (30) days prior to admission or within twenty four (24) hours after admission:

a) the history and physical shall be completed and documented no more than thirty (30) days before or twenty four (24) hours after admission or registration, but prior to surgery or procedure requiring anesthesia services; and placed in the patient’s medical record within twenty four (24) hours after admission or registration, but prior to surgery or procedure requiring anesthesia services.

b) when the history and physical is completed within thirty (30) days prior to admission or registration, an updated medical record entry documenting an examination for any changes in the patient’s condition shall be completed and documented in the patient’s medical record within twenty four (24) hours after admission or registration, but prior to surgery or procedure requiring anesthesia services.

SR.2 Admitting diagnosis;

SR.3 Results of all consultative evaluations of the patient and appropriate finding by clinical and other staff involved in the care of the patient;

SR.4 Documentation of complications, hospital acquired infections, and adverse reactions to drugs and anesthesia;

SR.5 Properly executed informed written consent forms for procedures and treatments specified by the medical staff, or by National or local law if applicable, signed by the patient or his/her authorized representative;

SR.6 Medical care plans, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient's condition;

SR.7 Discharge summary with outcome of hospitalization, the prognosis, and provisions for follow up care;

Page 44

DNV Standard for Hospitals, DNV-DS-HC101 December 2011, Version 2.0 S E C T IO N 2 5

Section 25 Discharge Planning (DC)