Indiana Administrative Code
Title 410 - INDIANA DEPARTMENT OF HEALTH
Article 26 - ABORTION CLINICS
Rule 7 - Medical Records
Section 7-2 - Content of the medical record
Universal Citation: 410 IN Admin Code 7-2
Current through March 20, 2024
Authority: IC 16-21-1-7; IC 16-21-2-2.5
Affected: IC 16-21-1; IC 16-21-2; IC 16-34-2-1.1
Sec. 2.
(a) The medical record for surgical abortions must be accurate and contain sufficient information to do the following:
(1) Identify
the patient to include name, age, and address.
(2) Document the following:
(A) Tests, examinations, and procedures
performed.
(B) The course of the
patient's stay in the clinic and the results.
(C) Evidence that the patient was provided
the hotline telephone number for assistance to patients who are:
(i) coerced into an abortion; or
(ii) victims of sex
trafficking.
(D) Evidence
of appropriate informed consent for procedures and treatments as required by IC
16-34-2-1.1.
(E) Any report filed with a state agency or
law enforcement agency pursuant to a statutory reporting
requirement.
(b) Entries in the medical record must be as follows:
(1) Legible.
(2) Complete.
(3) Made by authorized individuals as
specified in clinic and medical staff policies.
(4) Authenticated and dated in accordance
with this article.
(c) Patient records for surgical abortions must document and contain, at a minimum, the following:
(1) Appropriate medical
history.
(2) Results of the
following:
(A) A physical
examination.
(B) Diagnostic or
laboratory studies, or both (if performed).
(3) Any allergies and abnormal drug
reactions.
(4) Entries related to
anesthesia administration.
(5) A
report describing techniques, findings, and tissue removed or
altered.
(6) Authentication of
entries by the physician or physicians and health care workers who treated or
cared for the patient.
(7)
Condition on discharge, disposition of the patient, and time of
discharge.
(8) Discharge entry to
include instructions to the patient or patient's legal
representative.
(9) A copy of the
following:
(A) The transfer form if the
patient was referred to a hospital or other facility.
(B) The terminated pregnancy report filed
with the department.
(C) Any
document signed by the patient.
(d) An appropriate history and physical examination report must be in the patient's chart before a surgical abortion. The report shall include, but is not limited to, the following:
(1) Vital signs.
(2) Allergies.
(3) Any significant risk factors.
(4) The date written.
Disclaimer: These regulations may not be the most recent version. Indiana 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.
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