(a) Medical records shall be originated on all patients undergoing surgery, signed by the responsible physician, indexed and so filed as to ensure their ready access and future availability. They shall be maintained in accordance with a written retention policy acceptable to the Director of the Department of Welfare. 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, the following:
(1) Patient identification, including name, address, marital status and birthdate;
(2) Medical history;
(3) Physical examination;
(4) Medical orders signed by the responsible physician;
(5) Laboratory findings;
(6) Special examination findings, e.g., x-ray or electrocardiogram;
(7) Preoperative and final diagnosis;
(8) Nurses' notes which shall include a recording of vital signs, pre-and postoperatively, color, appearance and other relevant observations with such frequency postoperatively as to document the patient's stabilized condition at the time of discharge;
(9) A record of the sedation and anesthetic used by product name and dosage, the identity of the anesthetist if other than the surgeon, the type of procedure and any pertinent information concerning results or reactions;
(10) Written consultation reports signed by the consultant;
(11) Social or social service information relevant to the case;
(12) The surgeon's operative notes, including naming the procedure performed, the physician performing the surgery, and the anesthetic agent used, names of assistants (whether another physician, a nurse or a specially trained technician), the duration of the procedure, any unusual problem or occurrence encountered, and the surgeon's description of gross appearance of tissues removed;
(13) The physician's progress and discharge notes, which may be combined in the patient's clinical record;
(14) A summary of instructions given for followup observation and care as well as a record of all referrals for counseling, family planning or other medical conditions requiring further attention; and
(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 of Welfare.
(d) Medical records shall be maintained as confidential documents with the following exceptions:
(1) Information required under this chapter;
(2) Information required by other law; and
(3) Information authorized for disclosure by written release by the patient.
(e) A facility in which abortions are performed shall maintain records of the procedures and shall file reports and furnish statistical and such other information as may be required by the Director of the Department of Welfare. The Director shall take adequate measures to protect the confidentiality of the identity of patients from the public.
Reports shall be filed on forms provided by the Director, which reports shall include, at a minimum, the following information about each patient:
(1) The name and address of the facility;
(2) The patient number (the identity of the patient to be kept separate from the patient number on public records);
(3) The date of the abortion;
(4) The zip code of the residence of the pregnant female;
(5) The age of the pregnant female and, if know, of the impregnating male;
(6) The race of the patient;
(7) Marital status of the pregnant female and, if known, of the impregnating male;
(8) The number of previous pregnancies;
(9) Years of education;
(10) The number of living children;
(11) The number of previous induced abortions, spontaneous abortions and still-births;
(12) The date of the last induced abortion;
(13) The date of the last live birth and the health of the child at birth;
(14) The date of the beginning of the last menstrual period;
(15) The stated reason for the abortion;
(16) The medical condition of the female at the time of the abortion;
(17) The blood type and Rh type;
(18) The type of abortion procedure;
(19) The medical indication for abortion, if any;
(20) Complications noted, if any, from previous or present termination procedures; and
(21) All certifications required by this chapter.
The report shall be signed in each instance by the physician performing the procedure. The report forms shall not require particular identification of the patient undergoing the procedure.
(f) An individual complication report shall be submitted to the Department of Welfare by any physician who treats a patient who has received treatment in a facility licensed under this chapter. Such report shall include:
(1) The date of the original procedure;
(2) The name and address of the facility where the original procedure was performed; and
(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 responsible physician, is sufficient cause for immediate revocation of a license issued pursuant to this chapter.
(h) Information submitted by a referral source shall become an integral part of the clinical record of the patient.
(i) The Department of Welfare shall be responsible for collecting, collating and evaluating all data gathered from the reports required by this section. Information and data which are not privileged will be made available to the public upon request.
(j) The Department shall make report forms available to all facilities licensed under this chapter. Such forms may be used by such facilities to meet their reporting requirements.
(k) Adequate space shall be provided for the storage of medical records so located as to ensure their confidentiality and to 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.
(Ord. 1978-72. Passed 10-18-78.)