La. Admin. Code tit. 48 § I-6753

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-6753 - Medical Records

A. Medical Record System. Each hospital shall have an organized medical record system.

B. Facilities. The medical records room or area shall be conveniently located, sufficiently large, and adequately equipped to permit the proper handling of hospital medical records.

C. Medical Records. An accurate and complete medical record shall be written for each patient and filed in an accessible manner in the hospital.

D. Patient's Basic Medical Records. The following minimum data shall be kept on all patients:

1. identifying and sociological data;

2. dates of admission and discharge;

3. medical history;

4. physical examination and findings;.

5. medical orders;

6. progress notes;

7. summary report of patient's course in the hospital and condition on discharge;

8. record of all medical care of treatments;

9. reports of diagnostic procedures such as laboratory and X-ray;

10. nurse's record of care given to patients;

11. the above data may be kept on separate or combined record forms;

12. items 3 through 8 shall be written, dictated, or prepared by or under the supervision of the attending physician and the face sheet of the complete chart shall be signed by him;

13. the following additional data shall be kept when indicated:

a. consultation notes, signed by the consultant;

b. authorization, consent, or release forms;

c. operative record;

d. anesthesia report;

e. pathological reports;

f. obstetrical records;

g. record of mother's labor, delivery, and postpartum period;

h. separate infant record:

i. date and time of birth;

ii. condition at birth;

iii. sex;

iv. weight at birth if condition permits weighing;

v. condition of infant at time of discharge.

E. Other Records and Reports. The following indexes, registers, and records are required. These may be separate or combined:

1. patients' register;

2. birth register;

3. delivery room register;

4. operating room register;

5. death register;

6. analysis of hospital service, based on patient statistics;

7. daily census report of admissions, births, discharges, and deaths.

La. Admin. Code tit. 48, § I-6753

Promulgated by the Department of Health and Human Resources, Office of the Secretary, Division of Licensing and Certification, LR 13:246 (April 1987).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2100-2113.