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Ohio Administrative Code (Last Updated: January 12, 2021) |
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3701 Department of Health - Administration and Director |
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Chapter3701-83. Licensing Provisions for Health Care Facilities |
3701-83-21. Medical records - ambulatory surgical facilities
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Each medical record required by paragraph (A) of rule 3701-83-11 of the Administrative Code shall contain at least the following information as applicable for the surgery to be performed:
(A) Admission data:
(1) Name, address, date of birth, gender, and race or ethnicity;
(2) Date and time of admission; and
(3) Pre-operative diagnosis, which shall be recorded prior to or at the time of admission.
(B) History and physical examination data:
(1) Personal medical history, including but not limited to allergies, current medications and past adverse drug reactions;
(2) Family medical history; and
(3) Physical examination.
(C) Treatment data:
(1) Physician's, podiatrist's or dentist's orders;
(2) Physician's, podiatrist's or dentist's notes;
(3) Physician assistant's notes, if applicable;
(4) Nurse's notes;
(5) Medications;
(6) Temperature, pulse, and respiration;
(7) Any special examination or report, including but not limited to, x-ray, laboratory, or pathology reports;
(8) Signed informed consent form;
(9) Evidence of advanced directives and do-not-resuscitate orders, if applicable;
(10) Operative record;
(11) Anesthesia record, if applicable; and
(12) Consultation record, if applicable.
(D) Discharge data:
(1) Final diagnosis;
(2) Procedures and surgeries performed;
(3) Condition upon discharge;
(4) Post-treatment care and instructions; and
(5) Attending physician's, podiatrist's or dentist's signature.
(E) Other information required by law.