North Carolina Administrative Code
Title 10A - HEALTH AND HUMAN SERVICES
Chapter 13 - NC MEDICAL CARE COMMISSION
Subchapter C - LICENSING OF AMBULATORY SURGICAL FACILITIES
Section .1000 - MEDICAL RECORDS SERVICES
Section 13C .1002 - INDIVIDUAL PATIENT RECORDS

Universal Citation: 10A NC Admin Code 13C .1002

Current through Register Vol. 39, No. 6, September 16, 2024

(a) Each patient's medical record shall be maintained in accordance with professional standards and shall include at least the following information:

(1) patient's identification, including name, address, date of birth, next of kin and a patient number;

(2) admitting diagnosis;

(3) preoperative history and physical examination pertaining to the procedure to be performed;

(4) anesthesia report;

(5) surgeon's operative report;

(6) anesthesiologist's or anesthetist's report if applicable;

(7) pertinent laboratory, pathology and X-ray reports;

(8) postoperative orders and follow-up care;

(9) discharge summary, including discharge diagnosis;

(10) record of informed consent; and

(11) physician's, dentist's, and nurse's progress notes.

(b) The administrator shall be responsible for safeguarding information on the medical record against loss, tampering, or use by unauthorized persons.

(c) Medical records shall be the property of the facility and shall not be moved from the premises wherein they are filed except by subpoena or court order.

(d) For licensing purposes the length of time that medical records are to be retained is dependent upon the need for their use in continuing patient care and for legal, research, or educational purposes. This length of time shall not be less than 20 years.

(e) Should a facility cease operation, there shall be an arrangement for preservation of records to insure compliance with these regulations. The Department shall be notified, in writing, concerning the arrangements.

Authority G.S. 131E-149;
Eff. October 14, 1978;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. December 23, 2017.

Disclaimer: These regulations may not be the most recent version. North Carolina 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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