Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.106 - HEALTH CARE FACILITIES
Subchapter 37.106.5 - Minimum Standards for Outpatient Centers for Surgical Services
Rule 37.106.512 - MEDICAL, CLINICAL, AND HEALTH RECORD INFORMATION
Universal Citation: MT Admin Rules 37.106.512
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;
(b) significant
medical history and results of physical examination;
(c) preoperative diagnostic studies, if
performed;
(d) findings and
techniques of the operation including a pathologist's report on all tissues
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 which includes
notice of transfer when deemed appropriate;
(h) discharge diagnosis; and
(i) discharge recommendations and
instructions given to the patient.
(2) To ensure confidentiality, security, and physical safety of a patient's medical record, the outpatient center must designate a person to oversee and manage the clinical records.
(3) The outpatient center 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.
50-5-103, MCA; IMP, 50-5-103, MCA;
Disclaimer: These regulations may not be the most recent version. Montana 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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