Section 563.12. Form and content of record

The ASF shall maintain a separate medical record for each patient. Every record shall be accurate, legible and promptly completed. Patient medical records shall be constructed to stand alone and be easily identified as ASF records. Medical records shall include at least the following:

(1) Patient identification.

(2) Pertinent medical history and results of physical examination.

(3) Preoperative diagnostic studies—entered before surgery—if performed.

(4) The presence or absence of allergies and untoward drug reactions recorded in a prominent and uniform location in all patient charts on a current basis.

(5) Documentation of properly executed, informed patient consent.

(6) Entries related to anesthesia administration.

(7) Findings and techniques of the operation, including a pathologist report on tissue removed during surgery.

(8) Notes by authorized staff members and individuals who have been granted clinical privileges, nurses’ notes and entries by other professional personnel.

(9) Written and verbal disposition recommendations and instructions given to the patient.

(10) Significant medical advice given to a patient by telephone.

(11) Discharge summary including discharge diagnosis.

The provisions of this § 563.12 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256581).

Notation

Cross References

This section cited in 28 Pa. Code § 563.13 (relating to entries).