Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.106 - HEALTH CARE FACILITIES
Subchapter 37.106.31 - Minimum Standards for Abortion Clinics
Rule 37.106.3107 - MINIMUM STANDARDS FOR ABORTION CLINICS: PATIENT FILES
Universal Citation: MT Admin Rules 37.106.3107
Current through Register Vol. 18, September 20, 2024
(1) An individual clinical record must be established for each person receiving care. Each record must be accurate, legible, and promptly completed. The record must include at least the following:
(a) patient identification
including the patient's full name, sex, address, date of birth, and next of kin
(for minor patients) or emergency contact (for adult patients);
(b) admitting diagnosis;
(c) significant medical history and results
of physical examination;
(d)
anesthesia reports;
(e) procedure
reports;
(f) pertinent laboratory
and pathology reports as indicated and tests for RH Negative factor. A
pregnancy test or pathological exam of tissue shall be recorded to verify
pregnancy;
(g) nurses' notes
including admission, preoperative, and recovery;
(h) preoperative and postoperative
orders;
(i) any allergies and
abnormal drug reactions;
(j)
discharge note, discharge diagnosis, and instructions given to the
patient;
(k) documentation of
properly executed informed patient consent which includes notice of transfer
when deemed appropriate; and
(l)
documentation:
(i) that the patient was
provided a hotline telephone number for women who are coerced into an abortion
or who are victims of rape, incest, or sex trafficking;
(ii) of the assistance provided to the
patient if abortion clinic staff suspect the patient may be coerced into an
abortion or may be the victim of rape, incest, or sex trafficking;
and
(iii) of compliance with any
applicable mandatory reporting requirements with respect to the
patient.
(2) To ensure confidentiality, security, and physical safety of a patient's medical record, the abortion clinic must designate a person to oversee and manage the clinical records.
(3) The abortion clinic must have policies concerning clinical records. The policies must include:
(a) the retention of active
records;
(b) the retirement of
inactive records;
(c) the timely
entry of data in records; and
(d)
the release of information contained in records.
AUTH: 50-20-903, MCA; IMP: 50-20-903, MCA
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