Section 481.51.12. Records and reports.

         51.12(1) Medical records. Accurate and complete medical records shall be maintained for all patients and signed by the appropriate provider. These records shall be filed and stored in an accessible manner and in accordance with the statute of limitations as specified in Iowa Code chapter 614.

         51.12(2) Hospital records.

            a.                Admission records. A register of all admissions to the hospital shall be maintained.

            b.                Death records. A record of all deaths in the hospital shall be kept, including all information required on a standard death certificate as specified in Iowa Code chapter 144.

            c.                Birth records. A record of all births in the hospital shall be kept, including all information required on a standard birth certificate as specified in Iowa Code chapter 144.

            d.                Controlled substance records. Controlled substance records shall be maintained in accordance with state and federal laws, rules and regulations.

         51.12(3) Electronic records. In addition to the access provided in 481—subrule 50.10(2), an authorized representative of the department shall be provided unrestricted access to electronic records pertaining to the care provided to the patients of the hospital.

            a.               If access to an electronic record is requested by the authorized representative of the department, the hospital may provide a tutorial on how to use its particular electronic system or may designate an individual who will, when requested, access the system, respond to any questions or assist the authorized representative as needed in accessing electronic information in a timely fashion.

            b.               The hospital shall provide a terminal where the authorized representative may access records.

            c.               If the hospital is unable to provide direct print capability to the authorized representative, the hospital shall make available a printout of any record or part of a record on request in a time frame that does not intentionally prevent or interfere with the department’s survey or investigation.

[ARC 2472C, IAB 3/30/16, effective 5/4/16]