documents that such a release would have an adverse effect on the patient or another person. (e) Access to all medical records of patients will be afforded to members of the Medical Staff for bona fide study and research Projects consistent with Hospital policy, applicable federal and state law, and preserving the confidentiality of personal information concerning the individual patients. All such Projects will be approved by The Christ Hospital Institutional Review Board (TCHIRB). (f) Subject to the discretion of the President & Chief Executive Officer (or his or her designee), former members of the Medical Staff may be permitted access to information from the medical records of their patients covering all periods during which they attended to such patients in the Hospital. 3.3. Content of Record: (a) For every patient treated as an inpatient, a medical record will contain information to justify the medical necessity of the admission, continued hospitalization, and/or surgery or procedure. The medical record will describe the patient’s progress and response to medications and services. Medical records will also be kept for every scheduled ambulatory care patient and for every patient receiving emergency services. (b) Medical record entries will be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with the Hospital’s policies and procedures. Stamped signatures are not permitted in the medical record. (c) General Requirements. All medical records for patients receiving care in the hospital setting or at a Hospital-based ambulatory care location will document the information outlined in this paragraph, as relevant and appropriate to the patient’s care. This documentation will be the joint responsibility of the responsible practitioners and the Hospital: (1) identification data, including the patient’s name, sex, address, date of birth, and name of authorized representative; (2) status of any patient receiving behavioral health services; (3) patient’s language and communication needs, including preferred language for discussing health care; (4) authenticated or co-signed order for inpatient admission prior to discharge;
documents that such a release would have an adverse effect on the patient or another person. (e) Access to all medical records of patients will be afforded to members of the Medical Staff for bona fide study and research Projects consistent with Hospital policy, applicable federal and state law, and preserving the confidentiality of personal information concerning the individual patients. All such Projects will be approved by The Christ Hospital Institutional Review Board (TCHIRB). (f) Subject to the discretion of the President & Chief Executive Officer (or his or her designee), former members of the Medical Staff may be permitted access to information from the medical records of their patients covering all periods during which they attended to such patients in the Hospital. 3.3. Content of Record: (a) For every patient treated as an inpatient, a medical record will contain information to justify the medical necessity of the admission, continued hospitalization, and/or surgery or procedure. The medical record will describe the patient’s progress and response to medications and services. Medical records will also be kept for every scheduled ambulatory care patient and for every patient receiving emergency services. (b) Medical record entries will be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with the Hospital’s policies and procedures. Stamped signatures are not permitted in the medical record. (c) General Requirements. All medical records for patients receiving care in the hospital setting or at a Hospital-based ambulatory care location will document the information outlined in this paragraph, as relevant and appropriate to the patient’s care. This documentation will be the joint responsibility of the responsible practitioners and the Hospital: (1) identification data, including the patient’s name, sex, address, date of birth, and name of authorized representative; (2) status of any patient receiving behavioral health services; (3) patient’s language and communication needs, including preferred language for discussing health care; (4) authenticated or co-signed order for inpatient admission prior to discharge;
Rules%20Regulations%20041817.DOCX