North Carolina Administrative Code
Title 10A - HEALTH AND HUMAN SERVICES
Chapter 13 - NC MEDICAL CARE COMMISSION
Subchapter B - LICENSING OF HOSPITALS
Section .3900 - MEDICAL RECORD SERVICES
Section 13B .3906 - CONTENTS
Universal Citation: 10A NC Admin Code 13B .3906
Current through Register Vol. 39, No. 6, September 16, 2024
(a) The medical record shall contain sufficient information to justify the diagnosis, verify the treatment and document the course of treatment and results accurately.
(b) All in-patient records shall include the following information:
(1) identification data (name, address, age,
sex) and, when the identification data is not obtainable, the reason for
such;
(2) date and time of
admission and discharge;
(3)
medical history:
(A) chief
complaint;
(B) details of the
present illness;
(C) relevant past,
social, and family histories; and
(D) reports of relevant physical
examinations;
(4)
diagnostic and therapeutic orders;
(5) reports of procedures, tests and their
results;
(6) provisional or
admitting diagnosis;
(7) evidence
of appropriate informed consent or a written statement explaining why consent
was not obtained;
(8) clinical
observations, including results of therapy;
(9) record of medication and treatment
administration;
(10) progress notes
of all disciplines;
(11)
conclusions at termination of hospitalization or evaluation and
treatment;
(12) all relevant
diagnosis established by the time of discharge;
(13) consultation reports;
(14) surgical record, including anesthesia
record, pre-operative diagnosis, surgeon's operative report and post-operative
orders and any instructions given to the patient or family; and
(15) autopsy findings, if
performed.
Authority
G.S.
131E-79;
Eff. January 1,
1996;
Pursuant to
G.S.
150B-21.3A, rule is necessary without
substantive public interest Eff. July 22,
2017.
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