28-34-9a  Medical records services. (a)
General provisions. Each hospital shall maintain
medical records for each patient admitted for
care. The records shall be documented and read-
ily retrievable by authorized persons.

    (b)  Organization and staffing.

    (1)  Each hospital shall have a medical records
service that is directed, staffed, and equipped to
enable the accurate processing, indexing, and fil-
ing of all medical records. The medical records
service shall be under the direction of a person
who is a registered health information administra-
tor or a registered health information technician
as certified by the American health information
management association, or who meets the edu-
cational or training requirements for this certifi-
cation.

    (2)  If the employment of a full-time registered
health information administrator or registered
health information technician is impossible, the
hospital shall employ a registered records admin-
istrator or an accredited records technician on a
part-time consultant basis. The consultant shall
organize the department, train full-time person-
nel, and make periodic visits to evaluate the rec-
ords. There shall be a written contract between
the hospital and the consultant that specifies the
consultant's duties and responsibilities.

    (3)  At least one full-time employee shall pro-
vide regular medical records service.

    (c)  Facilities. The medical records department
shall be properly equipped to enable its personnel
to function in an effective manner and to maintain
medical records so that the records are readily ac-
cessible and secure from unauthorized use.

    (d)  Policies and procedures.

    (1)  Each medical record shall be kept on file
for 10 years after the date of last discharge of the
patient or one year beyond the date that the minor
patient reached the age of majority, whichever is
longer.

    (2)  If a hospital discontinues operation, the
hospital shall inform the licensing agency of the
location of its records.

    (3)  A summary shall be maintained of medical
records that are destroyed. This summary shall be
retained on file for at least 25 years and shall in-
clude the following information:

    (A)  The name, age, and date of birth of the
patient;

    (B)  the name of the patient's nearest relative;

    (C)  the name of the attending and consulting
practitioners;

    (D)  any surgical procedure and date, if appli-
cable; and

    (E)  the final diagnosis.

    (4)  Medical records may be microfilmed after
completion. If the microfilming is done off the
premises, the hospital shall take precautions to as-
sure the confidentiality and safekeeping of the
records.

    (5)  Each record shall be treated as confidential.
Only persons authorized by the governing body
shall have access to the records. These persons
shall include individuals designated by the licens-
ing agency for the purpose of verifying compli-
ance with state or federal statutes or regulations
and for disease control investigations of public
health concern.

    (6)  Medical records shall be the property of the
hospital and shall not be removed from the hos-
pital premises except as authorized by the govern-
ing body of the hospital or for purposes of litiga-
tion when specifically authorized by Kansas law or
appropriate court order.

    (e)  Contents of medical records. Medical rec-
ords shall contain sufficient information to iden-
tify the patient clearly, to justify the diagnosis and
treatment, and to document the results accu-
rately. At a minimum, each record shall include
the following:

    (1)  Notes by authorized house staff members
and individuals who have been granted clinical
privileges, consultation reports, nurses' notes, and
entries by designated professional personnel;

    (2)  findings and results of any pathological or
clinical laboratory examinations, radiology exami-
nations, medical and surgical treatment, and other
diagnostic or therapeutic procedures; and

    (3)  provisional diagnosis, primary and second-
ary final diagnosis, a clinical resume, and, if ap-
propriate, necropsy reports.

    (f)  Each entry in each record shall be dated and
authenticated by the person making the entry.
Verbal orders, including telephone orders, shall
include the date and signature of the person re-
cording them. The prescribing or covering prac-
titioner shall authenticate the order within 72
hours of the patient's discharge or 30 days, which-
ever occurs first. Records of patients discharged
shall be completed within 30 days following dis-
charge. (Authorized by and implementing K.S.A.
65-431; effective May 1, 1986; amended June 28,
1993; amended Feb. 9, 2001.)