Section 250.2860  Medical Records

a)         Each program shall maintain an organized record system for collection of information necessary to serve the patient.

b)         All records shall be confidential and privileged.  The hospital shall establish a written policy and procedure detailing how confidentiality is maintained.

c)         The patient's comprehensive treatment plan shall be individualized and recorded in the patient's medical record.

d)         The treatment received by the patient shall be documented in a manner and with frequency so as to ensure that all active therapeutic efforts are included.

e)         Progress notes shall be recorded by individuals directly involved in any treatment modality.  The notes shall contain recommendations for revisions in the treatment plan when indicated as well as a precise assessment of the patient's progress in accordance with the original or revised treatment plan.

f)         All patient records must meet the confidentiality and privacy requirements as mandated in Section 20.1510.  In the event the service is discontinued, the records shall be stored so that confidentiality and security is maintained, in accordance with Section 250.1510.

g)         The discharge summary shall include a recapitulation of the patient's hospitalization, as well as recommendations from appropriate services concerning problems, plans for follow-up, and continuity of care.  The discharge summary also shall include a brief summary of the patient's condition upon discharge.

h)         All entries in the record shall be legible, dated, and completed with the signature of the authorized individual providing the service and making the entry. 

(Source:  Amended at 50 Ill. Reg. 8128, effective May 26, 2026)