Current through Register Vol. 48, No. 9, September 27, 2024
A. An organized
record shall be initiated and maintained for each patient. The record shall
contain: sufficient documented information to identify the patient; the person
responsible for each patient; the description of the diagnosis and the care,
treatment, procedures, and/or services provided, to include the course of
action taken and results; and the response and reaction to the care, treatment,
procedures, and/or services provided. All entries shall be indelibly written,
signed by the author, and dated.
B.
Specific entries/documentation shall include at a minimum:
1. Consultations by physicians or other
legally authorized health care providers;
2. Orders and recommendations for all care,
treatment, procedures, and/or services from physicians or other legally
authorized health care providers, completed prior to, or at the time of patient
arrival, and subsequently, as warranted;
3. Care, treatment, procedures, and/or
services provided;
4. Record of
administration of each dose of medication and procedures followed if an error
is made;
5. Special procedures and
preventive measures performed, e.g., isolation for symptoms of
tuberculosis;
6. Notes of
observation during recovery, to include vital signs pre- and
post-treatment/procedure;
7.
Discharge summary, including condition at discharge or transfer, instructions
for self-care and instructions for obtaining post-treatment/procedure emergency
care;
8. Special information, e.g.,
allergies, etc.
9. Signed informed
consent for treatment as required by HIPAA and, if applicable, consent for
participation in research;
10. If
applicable, anesthesia records of pertinent pre-treatment/procedure reports
including pre-anesthesia evaluation, type of anesthesia, technique and dosage
used, and post-anesthesia follow-up note.
11. Treatment/procedure report (dictated or
written into the record immediately after treatment/procedure) to include at
least:
a. Description of findings;
b. Techniques utilized to perform
treatment/procedure;
c. Specimens
removed, if applicable;
d. Primary
physician and assistants.
12. Reports of all laboratory, radiological,
and diagnostic procedures along with tests performed and the results
appropriately authenticated.
C. Except as required by law, patient records
may contain written and interpretative findings and reports of diagnostic
studies, tests, and procedures, e.g., interpretations of imaging technology and
video tapes without the medium itself.
