Patient Care Records — Retention — Authentication

TITLE 39 HEALTH AND SAFETY CHAPTER 13 HOSPITALS 39-1394. Patient care records — Retention — Authentication. (1) Retention. (a)  Hospital records relating to the care and treatment of a patient may be preserved in microfilm, other photographically reproduced form or electronic medium. Such reproduced and preserved copies shall be deemed originals for purposes of section 9-420 , Idaho Code. (b)  Clinical laboratory test records and reports may be destroyed five (5) years after the date of the test recorded or reported therein, pursuant to paragraph (d) of this subsection. (c)  X-ray films may be destroyed five (5) years after the date of exposure, or five (5) years after the patient reaches the age of majority, whichever is later, pursuant to paragraph (d) of this subsection, if there are in the hospital record written findings of a physician who has read such x-ray films. (d)  At any time after the retention periods specified in paragraphs (b) and (c) of this subsection, the hospital may, without thereby incurring liability, destroy such records, by burning, shredding or other effective method in keeping with the confidential nature of their contents, provided, however, that destruction of such records must be in the ordinary course of business and no record shall be destroyed on an individual basis. (e)  For purposes of this section, the term "hospital" shall include all facilities defined as hospitals in chapter 13, title 39 , Idaho Code. (2)  Authentication. (a)  Hospital records relating to orders for the care and treatment of a patient or for the administration of any drug or pharmaceutical must be authenticated to ensure accuracy and patient safety. (b)  All orders must be authenticated by the author of the order or another practitioner who is responsible for the care of the patient and who is authorized to write orders by hospital policy in accordance with state law. (c)  When telephone or oral orders must be used, they must be: (i)   Accepted only by personnel authorized to do so by medical staff policies and procedures, consistent with federal and state law; and (ii)  Authenticated in a timely manner as stipulated by hospital policy. (d)  Authentication may occur either manually, with the practitioner’s signature, or electronically by facsimile transmission signed by the practitioner or by means of a unique electronic code known only to the practitioner. (e)  Each hospital must have in place policies and mechanisms to assure timely authentication of all orders and to assure that only the author of an order or another practitioner who is responsible for the care of the patient and who is authorized to write orders by hospital policy in accordance with state law can authenticate the order.