(a) Medical records shall be originated on all patients undergoing surgery, signed by the responsible physician, indexed and so filed as to assure their ready access and future availability, They shall be maintained in accordance with a written retention policy acceptable to the Director. In a hospital operated facility, the record keeping shall be incorporated into the hospital medical records system, including and subject to its established retention policies.
(b) Medical records shall contain as a minimum:
(1) Patient identification, including the name, address, marital status and birth date.
(2) Medical history.
(3) Physical examination.
(4) Medical orders signed by the responsible physician.
(5) Laboratory findings.
(6) Special examination findings, for example, x-ray or electrocardiogram.
(7) Pre-operative and final diagnosis.
(8) Nurses' notes which shall include a recording of vital signs, preoperative and post-operative, color, appearance and other relevant observations with such frequency post-operative as to document the patient's stabilized condition at time of discharge.
(9) Record of the sedation and anesthetic used by product name and dosage.
(10) Written consultation reports signed by the consultant.
(11) Social or social service information relevant to the case.
(12) Surgeon's operative note, including naming of procedure performed, physician performing surgery, anesthetic agent used, names of assistants (whether another physician, a nurse or specially trained technician), duration of procedure and any unusual problems or occurrences encountered, and surgeon's description of gross appearance of tissues removed.
(13) Physician's progress noted and discharge note. The physician's progress and discharge notes may be combined in the patient's clinical record.
(14) Summary of instructions given for follow-up observation and care as well as recording of all referrals for counseling, family planning or other medical conditions requiring further attention.
(15) Identification of the physician who actually discharges the patient.
(c) Medical records shall be available for survey and review of content at any
time by authorized members of the Department.
(d) Medical records shall be maintained as confidential documents with the following exceptions:
(1) Information required under these rules.
(2) Information required by law.
(3) Information authorized for disclosure by written request by the patient.
(e) A facility in which abortions are performed shall maintain records of all procedures, shall file reports and furnish statistical and such other information as may be required by the Director. Such information shall only be supplied to the Director biannually. The Director shall take adequate measures to protect the confidentiality of identity of the patient from the public.
There shall be reported on forms provided by the Director which shall include at a minimum the following information:
(1) Name and address of the facility.
(2) Patient number, with the identity of the patient to be kept separate from the patient number on public records.
(3) Date of abortion.
(4) Zip code of residence of pregnant female.
(5) Age of pregnant female, and age of impregnating male. if known
(6) Race.
(7) Marital status of pregnant female and impregnating male, if known.
(8) Number of previous pregnancies.
(9) Years of education
(10) Number of living children.
(11) Number of previous induced abortions, spontaneous abortion and stillbirths.
(12) Date of last induced abortion.
(13) Date of last live birth and health of such child at birth.
(14) Date of beginning of last menstrual period.
(15) Stated reason for abortion.
(16) Medical condition of female at time of abortion.
(17) Blood type and RH type.
(18) Type of abortion procedure.
(19) Medical indication for abortion, if any.
(20) Complications noted, if any, from previous or present termination procedures.
(21) All certifications required by this chapter.
The report shall be signed in each instance by the physician performing the procedure. The report for it shall not require particular identification of the patient undergoing the procedure.
(f) An individual complication report shall be submitted to the Department by any physician who treats a patient who has received treatment in a freestanding surgical outpatient facility. This report shall include:
(1) The date of the original procedure.
(2) The name and address of the freestanding surgical outpatient facility where the original procedure was performed.
(3) The nature of the complication observed and the treatment rendered.
(g) Failure or refusal of a facility to file the notification of termination of pregnancy, properly executed and personally signed by the reputable physician, is sufficient cause for immediate revocation of license.
(h) Information submitted by a referral source shall become an integral part of the clinical record of the patient.
(i) The Department shall be responsible for collecting, collating and evaluating all data gathered from the reports required by this chapter. Information and data not privileged will be made available to the public upon request.
(j) The Department shall make report forms available to all freestanding surgical outpatient facilities. Such forms may be used by these facilities to meet their reporting requirements.
(k) Adequate space shall be provided for the storage of medical records so located as to assure their confidentiality and protect them from access by unauthorized persons. Additional work space in or adjacent to the medical records storage area shall be provided for the assembly, completion and review of medical records.