3701-83-21 Medical records - ambulatory surgical facilities.
Each
ASFmedical 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.
Effective:
Five Year Review (FYR) Dates:
07/01/2016
02/16/2016 and 02/15/2021
CERTIFIED ELECTRONICALLY
Certification
04/22/2016
Date
Promulgated Under:
119.03
Statutory Authority:
3702.13, 3702.30
Rule Amplifies:
3702.12, 3702.13, 3702.30
Prior Effective Dates:
1/13/1996, 9/5/02
Document Information
- Effective Date:
- 7/1/2016
- File Date:
- 2016-04-22
- Last Day in Effect:
- 2016-07-01
- Five Year Review:
- Yes
- Rule File:
- 3701-83-21_PH_FF_A_RU_20160422_1009.pdf
- Related Chapter/Rule NO.: (1)
- Ill. Adm. Code 3701-83-21. Medical records