Ref: S&C 18-10-ALL lays out the summary as follows:
- Texting patient information among members of the health care team is permissible if accomplished through a secure platform.
- Texting of patient orders is prohibited regardless of the platform utilized
- Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider
- §489.24(b) Standard: Form and retention of record. The hospital must maintain a medical recordfor each inpatient and outpatient. Medical records must be accurately written, promptlycompleted, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protectsthe security of all record entries.
- (1) Medical records must be retained in their original or legally reproduced form for a period ofat least 5 years.
- (3) The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with Federal or State laws, court orders, or subpoenas.
- (4) All records must document the following, as appropriate:
- (i) Evidence of — (vi) All practitioners’ orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition.