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PDFWAC 388-107-0570

Resident recordsSystem.

(1) The enhanced services facility must:
(a) Designate an individual responsible for the record system who:
(i) Has appropriate training and experience in clinical record management; or
(ii) Receives consultation from a qualified clinical record practitioner, such as a registered health information administrator or registered health information technician.
(b) Make all records available for review by:
(i) Authorized representatives of the department;
(ii) Representatives of the long term care and mental health ombud's office with authorization or permission from the resident or resident's representative;
(iii) Representatives of disability rights Washington; and
(iv) Representatives of the Washington state fire marshal when conducting fire safety inspections.
(c) Maintain the following:
(i) A master resident index having a reference for each resident including the health record number, if applicable; full name; date of birth; admission dates; and discharge dates; and
(ii) A chronological census register, including all admissions, discharge, deaths and transfers, and noting the receiving facility. The enhanced services facility must ensure the register includes discharges and transfers to other treatment facilities in excess of twenty-four hours.
(2) The enhanced services facility must ensure the clinical record of each resident:
(a) Is documented and authenticated accurately, promptly and legibly by individuals giving the order, making the observation, performing the examination, assessment, treatment or providing the care and services. "Authenticated" means the authorization of a written entry in a record by signature, including the first initial and last name and title, or a unique identifier allowing identification of the responsible individual; and:
(i) Documents from other health care facilities that are clearly identified as being authenticated at that facility will be considered authenticated at the receiving facility; and
(ii) The original or a durable, legible, direct copy of each document will be accepted.
(b) Contains appropriate information for a deceased resident including:
(i) The time and date of death;
(ii) Apparent cause of death;
(iii) Notification of the physician and appropriate resident representative; and
(iv) The disposition of the body and personal effects.
[Statutory Authority: Chapter 70.97 RCW. WSR 14-19-071, § 388-107-0570, filed 9/12/14, effective 10/13/14.]
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