§ 77139. Health Record Service.

(a) The facility shall maintain a health record service in accordance with accepted professional standards and practices. The health record service shall have sufficient staff, facilities and equipment and be conveniently located to facilitate the accurate processing, checking, indexing and filing of all health records.

(b) The health record service shall be under the direction of a staff member who has training and experience in records administration. This designated staff member shall be assisted by such qualified personnel as are necessary to conduct the service. A registered record administrator or accredited records technician shall provide consultation as necessary to designated staff members responsible for record administration.

(c) If a facility, in addition to inpatient services, is providing structured outpatient services or crisis intervention, a unit health record system shall be established.

(d) The facility shall have a continuing system of collecting and recording data that describe patients served in such form as to provide for continuity of care, programming services, and data retrieval for program, patient care evaluation, and research. Health records shall be stored and systematically organized to facilitate retrieving of information.

(e) Policies and procedures shall be established and implemented to ensure the confidentiality of an authorized access to patient health information, in accordance with federal, state, and local laws and acceptable standards of practice.

HISTORY

1. New section filed 4-15-87, operative 5-15-87 (Register 87, No. 16).

2. Amendment of subsection (c) and amendment of Note filed 5-7-99; operative 6-6-99 (Register 99, No. 19).

Note

Note: Authority cited: Sections 1254(e) and 1275, Health and Safety Code. Reference: Sections 1250.2(b), 1266.1(f) and 1275.1, Health and Safety Code.