3701-83-21 Medical records.

 

3701-83-21                  Medical records.

 

 

Each ASF medical record shall contain at least the following information as applicable for the surgery to be performed:

 

(A)  Admission data:

 

(1)   Name, address, birth date, sex, marital status, and race 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, 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:                                9/5/2002

R.C. 119.032 review dates:    2/28/2002 and 02/28/2006

CERTIFIED ELECTRONICALLY

Certification

08/26/2002 03:50 PM

Date

Promulgated Under:   119.03

Statutory Authority:   3702.13, 3702.30

Rule Amplifies:           3702.12, 3702.13, 3702.30

Prior Effective Dates: 1/13/96