Current through Register Vol. 50, No. 9, September 20, 2024
A.
Medical Record System. Each hospital shall have an organized medical record
system.
B. Facilities. The medical
records room or area shall be conveniently located, sufficiently large, and
adequately equipped to permit the proper handling of hospital medical
records.
C. Medical Records. An
accurate and complete medical record shall be written for each patient and
filed in an accessible manner in the hospital.
D. Patient's Basic Medical Records. The
following minimum data shall be kept on all patients:
1. identifying and sociological
data;
2. dates of admission and
discharge;
3. medical
history;
4. physical examination
and findings;.
5. medical
orders;
6. progress
notes;
7. summary report of
patient's course in the hospital and condition on discharge;
8. record of all medical care of
treatments;
9. reports of
diagnostic procedures such as laboratory and X-ray;
10. nurse's record of care given to
patients;
11. the above data may be
kept on separate or combined record forms;
12. items 3 through 8 shall be written,
dictated, or prepared by or under the supervision of the attending physician
and the face sheet of the complete chart shall be signed by him;
13. the following additional data shall be
kept when indicated:
a. consultation notes,
signed by the consultant;
b.
authorization, consent, or release forms;
c. operative record;
d. anesthesia report;
e. pathological reports;
f. obstetrical records;
g. record of mother's labor, delivery, and
postpartum period;
h. separate
infant record:
i. date and time of
birth;
ii. condition at
birth;
iii. sex;
iv. weight at birth if condition permits
weighing;
v. condition of infant at
time of discharge.
E. Other Records and Reports. The following
indexes, registers, and records are required. These may be separate or
combined:
1. patients' register;
2. birth register;
3. delivery room register;
4. operating room register;
5. death register;
6. analysis of hospital service, based on
patient statistics;
7. daily census
report of admissions, births, discharges, and deaths.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
40:2100-2113.
