Section 410 IAC 26-7-2 - Content of the medical recordAuthority: IC 16-21-1-7; IC 16-21-2-2.5
Affected: IC 16-21-1; IC 16-21-2; IC 16-34-2-1.1
Sec. 2.
(a) The medical record for surgical abortions must be accurate and contain sufficient information to do the following:(1) Identify the patient to include name, age, and address.(2) Document the following: (A) Tests, examinations, and procedures performed.(B) The course of the patient's stay in the clinic and the results.(C) Evidence that the patient was provided the hotline telephone number for assistance to patients who are: (i) coerced into an abortion; or(ii) victims of sex trafficking.(D) Evidence of appropriate informed consent for procedures and treatments as required by IC 16-34-2-1.1.(E) Any report filed with a state agency or law enforcement agency pursuant to a statutory reporting requirement.(b) Entries in the medical record must be as follows:(3) Made by authorized individuals as specified in clinic and medical staff policies.(4) Authenticated and dated in accordance with this article.(c) Patient records for surgical abortions must document and contain, at a minimum, the following:(1) Appropriate medical history.(2) Results of the following: (A) A physical examination.(B) Diagnostic or laboratory studies, or both (if performed).(3) Any allergies and abnormal drug reactions.(4) Entries related to anesthesia administration.(5) A report describing techniques, findings, and tissue removed or altered.(6) Authentication of entries by the physician or physicians and health care workers who treated or cared for the patient.(7) Condition on discharge, disposition of the patient, and time of discharge.(8) Discharge entry to include instructions to the patient or patient's legal representative.(9) A copy of the following:(A) The transfer form if the patient was referred to a hospital or other facility.(B) The terminated pregnancy report filed with the department.(C) Any document signed by the patient.(d) An appropriate history and physical examination report must be in the patient's chart before a surgical abortion. The report shall include, but is not limited to, the following: (3) Any significant risk factors.Indiana State Department of Health; 410 IAC 26-7-2; filed May 11, 2006, 9:36 a.m.: 29 IR 3363; readopted filed Jul 12, 2012, 12:08 p.m.: 20120808-IR-410120196RFAReadopted filed 9/26/2018, 2:48 p.m.: 20181024-IR-410180328RFAFiled 9/6/2019, 3:25 p.m.: 20191002-IR-410190164FRA