Pennsylvania Code (Last Updated: April 5, 2016) |
Title 28. HEALTH AND SAFETY |
PART IV. Health Facilities |
Subpart F. Ambulatory Surgical Facilities |
Chapter 563. Medical Records |
Section 563.13. Entries
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(a) Entries in the record shall be dated and authenticated by the person making the entry.
(b) Symbols and abbreviations may be used only when they have been approved by the medical staff and when a legend exists to explain them.
(c) A single signature on the fact sheet of a record does not suffice to authenticate the entire record. Each entry shall be individually authenticated.
(d) Notation of unusual incidents shall be entered in the medical record.
(e) Necessary documentation on the patients medical record as specified in § 563.12 (relating to form and content of record) shall be completed in a timely manner not to exceed 30 days.
The provisions of this § 563.13 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256581).