37.106.402    MINIMUM STANDARDS FOR A HOSPITAL: MEDICAL RECORDS

Medical records shall comply with the following requirements:

(1) A patient's entire medical record must be maintained, in either its original form or that allowed by ARM 37.106.314(3) , for not less than 10 years following the date of a patient's discharge or death, or, in the case of a patient who is a minor, for not less than 10 years following the date the patient either attains the age of majority or dies, if earlier.

(2) An obstetrical record shall be developed for each maternity patient and must include the prenatal record, labor notes, obstetrical anesthesia notes and delivery record.

(3) A record must be developed for each newborn, and shall include, in addition to the information in (2) , the following information:

(a) observations of newborn after birth;

(b) delivery room care of newborn;

(c) physical examinations performed on newborn;

(d) temperature of newborn;

(e) weight of newborn;

(f) time of newborn's first urination;

(g) number, character and consistency of newborn's stool;

(h) type of feeding administered to newborn;

(i) phenylketonuria report for newborn;

(j) name of person to whom newborn is released.

(4) A patient's entire medical record may be abridged following the dates established in (1) to form a core medical record of the patient's medical record. The core medical record or the microfilmed medical record should be maintained permanently but must be maintained not less than 10 years beyond the periods provided in (1) . A core record shall contain at a minimum the following information:

(a) identification of patient data which includes name, maiden name if relevant, address, date of birth, sex, and, if available, social security number;

(b) medical history;

(c) physical examination report;

(d) consultation reports;

(e) report of operation;

(f) pathology report;

(g) discharge summary, except that for newborns and others for whom no discharge summary is available, the final progress note must be retained;

(h) autopsy findings;

(i) for each maternity patient, the information required by (2) ; and

(j) for each newborn, the information required by (3) .

(5) Nothing in this rule may be construed to prohibit retention of hospital medical records beyond the period described herein or to prohibit the retention of the entire medical record.

(6) Diagnostic imaging film and electrodiagnostic tracings must be retained for a period of five years; their interpretations must be retained for the same periods required for the medical record in (1) , but need not be retained beyond those periods.

History: Sec. 50-5-103 and 50-5-404, MCA; IMP, Sec. 50-5-103, 50-5-106 and 50-5-404, MCA; NEW, 1980 MAR p. 1587, Eff. 6/13/80; AMD, 1986 MAR p. 1583, Eff. 9/26/86; AMD, 1990 MAR p. 1259, Eff. 6/29/90; TRANS, from DHES, 2002 MAR p. 185.