Current through Register Vol. 48, No. 9, September 27, 2024
A. Each entry in
the medical records must be legible, dated, timed and signed/authenticated by
the clinician or designee that created the entry. A medical record must be
created for all patients admitted to the hospital and newborns delivered in the
hospital. Initials will be accepted provided such initials can be readily
identified within the medical record. A minimum medical record shall include
the following information:
1. An admission
record must be prepared for each patient and must contain the following
information, when obtainable: Name; address, including county; age; date of
birth; sex; marital status; religion; race and ethnicity; health insurance
number; provisional diagnosis; case number; days of care; social security
number; name and telephone number of person or persons to be notified in the
event of emergency; name of referring physician; name of attending physician;
date and hour of admission;
2.
History and physical within 48 hours after admission;
3. Provisional or working
diagnosis;
4. Pre-operative
diagnosis;
5. Plan of
care;
6. Complete surgical record,
if any, including technique of operation and findings, statement of tissue and
organs removed and post-operative diagnosis;
7. Report of anesthesia;
8. Nurses' notes;
9. Progress notes;
10. Gross pathological findings and
microscopic, if applicable;
11.
Vital signs and other measurements appropriate to patient;
12. Medication Administration Record or
similar document for recording of medications, treatments and other pertinent
data. This record shall be signed/authenticated after each medication
administered or treatment is rendered;
13. Final diagnosis and discharge summary,
including date and time of discharge;
14. In case of death, cause and autopsy
findings, if autopsy is performed, unless the death becomes subject to review
by the coroner's office, and;
15.
Special examinations, if any, e.g., consultations, clinical laboratory, x-ray
and other examinations.
B. Contingent upon the availability of
pertinent information in the perinatal records of the mother, newborn records
should include the following:
1. History of
hereditary conditions in mother's and/or father's family;
2. First day of the last menstrual period
(L.M.P.) and estimated day of confinement (E.D.C.);
3. Mother's blood group and RH type -
evidence of sensitization and/or immunization (such as, administration of
anti-D hyperimmune globulin);
4.
Serological test including dates performed for syphilis, HIV, Rubella, and
Hepatitis B, results of any other tests performed during pregnancy (e.g., Group
B Strep, Chlamydia, Gonorrhea, Herpes);
5. Maternal disease (e.g., diabetes,
hypertension, pre-eclampsia, infections);
6. Drugs taken during pregnancy, labor and
delivery;
7. Results of
measurements of fetal maturity and well-being (e.g., lung maturity and
ultrasonography);
8. Duration of
ruptured membranes and labor, including length of second stage;
9. Method of delivery, including indications
for operative or instrumental interference;
10. Complications of labor and delivery
(e.g., hemorrhage or evidence of fetal distress), including a representative
strip of the fetal ECG if recorded;
11. Description of placenta at delivery,
including number of umbilical vessels;
12. Estimated amount and description of
amniotic fluid;
13. Apgar scores at
one and five minutes of age. Description of resuscitations, if required,
detailed description of abnormalities and problems occurring from birth until
transfer to the special nursery or the referral facility;
14. Results and date specimen was collected
for neonatal testing to detect inborn metabolic errors and hemoglobinopathies,
including PKU, hypothyroidism and various other metabolic disorders. Exception:
Parents may object because of religious grounds only, and in writing using a
form promulgated by the Department; and
15. Results and dates of pulse oximetry
screening and/or follow up of evaluation for critical congenital heart defects.
Exception: Parents may object only in writing to the
screening for reason pertaining to religious beliefs.
C. When restraints are utilized,
there must be an order to include length of time to be used and signed/
authenticated by the legally authorized healthcare provider approving use of
restraint or seclusion either at the time they are applied to a patient, or in
case of emergency, within 24 hours after they have been applied. Each procedure
manual shall contain information and instructions on the specific types of
safety precautions that may or may not be used.
