3701-83-23.3 Medical records.

 

3701-83-23.3               Medical records.

 

 

 

Each patient medical record required by paragraph (A) of Administrative Code rule 3701-83-11 shall contain at least the following information:

 

(A)Patient information including:

 

(1)Name, address, date of birth , gender, and race or ethnicity;

 

(2)History and physical examination data including allergies, current medications, past adverse drug reactions, and family medical history;

 

(3) Diagnosis; and

 

(4) Dialysis prescriptions.

 

(B)Treatment data including;

 

(1)Long term program and patient care plan;

 

(2) Progress notes; and

 

(3)Treatment notes including dates and times the patient was on or off dialysis, pre-dialysis safety checks, vital signs monitoring during dialysis, and notations of adverse reactions.

 

(C)Medication administration.

 

(D)Any special examination or report, including x-ray, laboratory, or pathology report.

 

(E)Signed consent for treatment form.

 

(F) Documentation  indicating  that  the  patient  or  patient's  representative  received  in writing the following:

 

(1) Information on complaint policies and grievance procedures;

 

(2) Information regarding the center's policy on advanced directives; and

 

(3) Information about the services to be performed.

 

(G)Documentation  indicating  that  the  patient  or  patient's  representative  received information about:

 

 

 

3701-83-23.3                                                                                                                         2

(1)Emergency self disconnect; and

(2)Measures  to  be  taken  in  the  event  of  an  at  home  post-treatment  medical emergency.

(H)Discharge data including, condition upon discharge, and post-discharge care and instructions.

Effective:                                9/5/2002

R.C. 119.032 review dates:    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: None