North Carolina Administrative Code
Title 10A - HEALTH AND HUMAN SERVICES
Chapter 13 - NC MEDICAL CARE COMMISSION
Subchapter B - LICENSING OF HOSPITALS
Section .4100 - EMERGENCY SERVICES
Section 13B .4107 - EMERGENCY RECORDS
Universal Citation: 10A NC Admin Code 13B .4107
Current through Register Vol. 39, No. 6, September 16, 2024
(a) The facility shall require all levels of emergency departments to maintain a continuous control register on each patient seen for services which shall include at least the name, age, sex, date, time, and means of arrival, nature of complaint, disposition, and time of discharge.
(b) The facility shall maintain a record for each patient seeking emergency care. This shall include:
(1) patient identification, time and means of
arrival;
(2) pertinent history and
physical findings and patient vital signs;
(3) diagnostic and therapeutic
orders;
(4) clinical observations
including results of treatment;
(5)
reports of procedures, tests and results;
(6) diagnostic impression; and
(7) discharge or transfer summary of
treatment including final disposition, the patient's condition, and any
instructions given to the patient and or family for follow-up care.
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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