Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 205 - AMBULATORY SURGICAL TREATMENT CENTER LICENSING REQUIREMENTS
Subpart F - RECORDS AND REPORTS
Section 205.610 - Clinical Records and Reports
Universal Citation: 77 IL Admin Code ยง 205.610
Current through Register Vol. 48, No. 12, March 22, 2024
a) The ASTC shall maintain accurate and complete clinical records for each patient, and all entries in the clinical record shall be made at the time the surgical procedure is performed and when care, treatment, medications, or other medical services are given. The record shall include, but not be limited to, the following:
1) Patient
identification;
2) Admitting
information, including any patient medical history and physical examination
findings as applicable, diagnosis or need for medical services, and all
consultation reports;
3)
Pre-counseling notes;
4) Signed
informed consent;
5) Confirmation
of a pregnancy (when an abortion is performed);
6) Signed physician orders;
7) Laboratory test reports, pathologist's
report of tissue or other specimens including foreign bodies, and physician's,
podiatrist's, dentist's or radiologist's report of imaging studies;
8) An anesthesia record;
9) The operative record, describing
techniques, findings and tissues or other items removed or altered, shall be
written or dictated immediately following surgery and signed by the surgeon.
The operative record shall include, but not be limited to:
A) The name and ASTC identification number of
the patient;
B) The date and time
of the surgery;
C) The names of the
surgeon or surgeons and assistants or other practitioners who performed
surgical tasks, including practitioners who performed those tasks under
supervision;
D) The pre-operative
and post-operative diagnosis;
E)
The name of the specific surgical procedure or procedures performed;
F) The type of anesthesia
administered;
G) Complications, if
any;
H) A description of
techniques, findings, and tissues or other items (such as foreign bodies)
removed or altered;
I) A
description of the specific significant surgical tasks that were conducted by
practitioners other than the primary surgeon or practitioner, including, but
not limited to, opening and closing, harvesting grafts, dissecting tissue,
removing tissue, implanting devices, altering tissues, or monitoring;
and
J) Prosthetic devices, grafts,
tissues, transplants or devices, if any, that were implanted in, or removed
from, the patient;
10)
Medication administration and medical treatments that were performed;
11) Recovery room progress notes;
12) Physician and nurse progress
notes;
13) The patient's condition
at time of discharge;
14) Patient
instructions; and
15)
Post-counseling notes.
b) The ASTC shall comply with the Pregnancy Termination Report Code.
c) Record Retention
1) The ASTC shall preserve and
retain a patient's clinical records, in a format established by the facility's
written policy, for not less than 10 years after the date of service. If the
patient was a minor on the date the record was produced, the records shall be
retained until the patient is 23 years old, or at least 10 years after the date
the record was produced, whichever is longer.
2) If the ASTC has been notified in writing
by an attorney of pending litigation involving a patient's clinical record
before the expiration of that record's retention period, the ASTC shall retain
the record until the ASTC receives documentation that the litigation involving
the record has been concluded, or for 10 years after the date of service,
whichever occurs later. If the litigation involves a patient who was a minor
when the record was produced, the ASTC shall retain the record until the
patient is 23 years old, or at least 10 years after the date the record was
produced, whichever is longer.
3)
The ASTC shall retain, for as long as it remains in business, a list of
organizational-approved procedures, pursuant to Sections
205.120(b)(10),
205.125(b)(9),
and
205.130(a).
4) The ASTC shall retain its sterilizer logs
for a minimum of three years.
5)
The ASTC shall retain its pharmacy narcotics receipts and inventory for a
minimum of three years.
d) An ASTC found in violation of this Section shall be penalized pursuant to Subpart H.
Disclaimer: These regulations may not be the most recent version. Illinois may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.