New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 370 - OVERSIGHT OF LICENSED HEALTHCARE FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS
Part 18 - REQUIREMENTS FOR FACILITIES PROVIDING OUTPATIENT MEDICAL SERVICES AND INFIRMARIES
Section 8.370.18.24 - PATIENT RECORDS

Universal Citation: 8 NM Admin Code 8.370.18.24

Current through Register Vol. 35, No. 18, September 24, 2024

Each facility licensed pursuant to these regulations 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. Ambulatory surgical centers:

(1) patient identification;

(2) significant medical history and results of physical examination;

(3) preoperative diagnostic studies (entered before surgery), if performed;

(4) findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body;

(5) any allergies and abnormal drug reactions;

(6) entries related to anesthesia administration;

(7) documentation of properly executed informed patient consent; and

(8) discharge diagnosis;

B. Diagnostic and treatment centers, rural health clinics, limited diagnostic and treatment centers:

(1) patient identification;

(2) patient consent forms (if applicable);

(3) pertinent medical history;

(4) assessment of the health status and health care needs of the patient;

(5) brief summary of the episode for which the patient is requiring care;

(6) disposition, and instructions to the patient;

(7) reports of physical examinations, diagnostic and laboratory test results, and consultative findings; and

(8) all physician's orders, reports of treatments and medication and other pertinent information necessary to monitor the patient's progress;

C. Infirmaries:

(1) same as Paragraphs (1) through (8) of Subsection B of 8.370.18.24 NMAC above;

(2) nursing notes (for those patients requiring overnight care or observation); and

(3) medication chart (if applicable);

D. New or innovative outpatient service:

(1) same as Paragraphs (1) through (8) of Subsection B of 8.370.18.24 NMAC above;

(2) any other information deemed necessary by the licensing authority after review and approval of the new or innovative service.

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