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PDFWAC 246-320-166

Management of information.

The purpose of this section is to improve patient outcomes and hospital performance through obtaining, managing, and using information.
Hospitals must:
(1) Provide medical staff, employees and other authorized persons with access to patient information systems, resources, and services;
(2) Maintain confidentiality, security, and integrity of information;
(3) Initiate and maintain a medical record for every patient assessed or treated including a process to review records for completeness, accuracy, and timeliness;
(4) Create medical records that:
(a) Identify the patient;
(b) Have clinical data to support the diagnosis, course and results of treatment for the patient;
(c) Have signed consent documents;
(d) Promote continuity of care;
(e) Have accurately written, signed, dated, and timed entries;
(f) Indicate authentication after the record is transcribed;
(g) Are promptly filed, accessible, and retained according to RCW 70.41.190 and chapter 5.46 RCW; and
(h) Include verbal orders that are accepted and transcribed by qualified personnel;
(5) Establish a systematic method for identifying each medical record, identification of service area, filing, and retrieval of all patient's records; and
(6) Adopt and implement policies and procedures that address:
(a) Who has access to and release of confidential medical records according to chapter 70.02 RCW;
(b) Retention and preservation of medical records according to RCW 70.41.190;
(c) Transmittal of medical data to ensure continuity of care; and
(d) Exclusion of clinical evidence from the medical record.
[Statutory Authority: Chapter 70.41 RCW and RCW 43.70.040. WSR 09-07-050, ยง 246-320-166, filed 3/11/09, effective 4/11/09.]
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