Cal. Code Regs. tit. 22 § 97530.7

Current through Register 2024 Notice Reg. No. 49, December 6, 2024

Section 97530.7 - Content of Medical Records

Each patient's medical record shall consist of at least the following:

(1) Identification sheet including but not limited to:

(A) Name.

(B) Address.

(C) Identification number, if applicable.

(D) Age.

(E) Sex.

(F) Date and time of admission.

(G) Date and time of discharge.

(H) Name, address, and telephone number of person or agency responsible for patient.

(I) Name of patient's attending surgeon.

(J) Identification of participating surgery program at which surgery was performed.

(2) Consent forms.

(3) Copy of patient's written medical records from the participating surgery program at which the surgery was performed that are available at the time of admission to the facility.

(4) Copy of the written report of the patient's pre-surgical physical examination.

(5) Copy of the signed plan for admission described in section 97520.3.

(6) Copy of the postsurgical pre-admission examination.

(7) Order sheet including medication, treatment and diet orders.

(8) Attending surgeon's notes.

(9) Reports of all laboratory tests performed during the patient's stay at the facility.

(10) Patient recovery care plan.

(11) Nurses' notes.

(12) Discharge report.

Cal. Code Regs. Tit. 22, § 97530.7

1. New section filed 3-7-88 as an emergency; operative 3-7-88 (Register 88, No. 12). No Certificate of Compliance required pursuant to the provisions of Health and Safety Code section 1250.9(m).
2. Editorial correction of HISTORY No. 1 (Register 90, No. 21).

Note: Authority cited: Section 1250.9, Health and Safety Code. Reference: Section 1250.9, Health and Safety Code.

1. New section filed 3-7-88 as an emergency; operative 3-7-88 (Register 88, No. 12). No Certificate of Compliance required pursuant to the provisions of Health and Safety Code section 1250.9(m).
2. Editorial correction of HISTORY No. 1 (Register 90, No. 21).