Current through Register Vol. 48, No. 9, September 27, 2024
A. The facility shall initiate and maintain an organized record 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, surgery, and/or services provided, to include the course of action taken and results; and the response and reaction to the care, treatment, procedures, surgery, and/or services provided. All entries shall be indelibly written, authenticated by the author, and dated.
B. Specific entries/documentation shall include at a minimum:
1. Consultations by physicians or other legally authorized healthcare providers;
2. Physical examination report, including pertinent medical history;
3. Orders and recommendations for all care, treatment, procedures, surgery, and/or services from physicians or other legally authorized healthcare providers, completed prior to, or at the time of patient arrival at the facility, and subsequently, as warranted;
4. Care, treatment, procedures, surgery, and/or services provided;
5. Record of administration of each dose of medication;
6. Medications administered and procedures followed if an error is made;
7. Special procedures and preventive measures performed, e.g., isolation for symptoms of tuberculosis;
8. Notes of observation during recovery, to include vital signs pre- and post-operative;
9. Discharge summary, including condition at discharge or transfer, instructions for self-care and instructions for obtaining postoperative emergency care;
10. Special information, e.g., allergies, etc. Documentation regarding organ donation shall be included in the record at the patient's request;
11. Signed informed consent;
12. If applicable, anesthesia records of pertinent preoperative and postoperative reports including pre-anesthesia evaluation, type of anesthesia, technique and dosage used, and post-anesthesia follow-up note;
13. Operative report (dictated or written into the record after surgery/procedure) to include at least:
a. Description of findings;
b. Techniques utilized to perform procedure/surgery;
c. Specimens removed, if applicable;
d. Primary surgeon and assistants.
14. 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.
