Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 125 - REGULATIONS GOVERNING THE LICENSING OF AMBULATORY SURGICAL FACILITIES
Chapter 4 - COMPLIANCE REQUIREMENTS
Section 144-125-4.I - Medical Records
Universal Citation: 10 ME Code Rules ยง 144-125-4.I
Current through 2024-38, September 18, 2024
The Ambulatory Surgical Facility must maintain complete, comprehensive and accurate medical records to ensure adequate patient care.
4.I.1. Organization
The Ambulatory Surgical Facility must develop and maintain a system for the proper collection, storage and use of patient records.
4.I.2. Form and Content of Record
The Ambulatory Surgical Facility must maintain a medical record for each patient. Every record must be accurate, legible and promptly completed. Medical records must include at least the following:
a. Patient identification
b. Significant medical history and results of
physical examination
c.
Pre-operative diagnostic studies (entered before surgery, if
performed).
d. Findings and
techniques of the operation, including a pathologist's report on all times
removed during surgery, except those exempted by the governing body
e. Any allergies and abnormal drug
reactions
f. Entries related to
anesthesia administration
g.
Documentation of properly executed informed patient consent
h. Discharge diagnosis.
Disclaimer: These regulations may not be the most recent version. Maine 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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