Louisiana Administrative Code
Title 48 - PUBLIC HEALTH-GENERAL
Part I - General Administration
Subpart 3 - Licensing and Certification
Chapter 93 - Hospitals
Subchapter H - Medical Record Services
Section I-9389 - Content

Universal Citation: LA Admin Code I-9389

Current through Register Vol. 50, No. 9, September 20, 2024

A. The medical record shall contain the following minimum data:

1. unique patient identification data;

2. admission and discharge dates;

3. complete history and physical examination, in accordance with medical staff policies and procedures;

4. provisional admitting diagnosis and final diagnosis;

5. medical staff orders;

6. progress notes;

7. nursing documentation and care plans;

8. record of all medical care or treatments; and

9. discharge summary.

B. The medical record shall contain the following when applicable:

1. clinical laboratory, pathological, nuclear medicine, radiological and/or diagnostic reports;

2. consultation reports;

3. pre-anesthesia note, anesthesia record, and post-anesthesia notes;

4. operative reports;

5. obstetrical records, including:
a. record of mother's labor, delivery, and postpartum period;

b. separate infant record containing date and time of birth, condition at birth, sex, weight at birth if condition permits weighing, and condition of infant at time of discharge;

c. autopsy reports; and/or

d. any other reports pertinent to the patient's care.

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2100-2115.

Disclaimer: These regulations may not be the most recent version. Louisiana 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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