La. Admin. Code tit. 48 § I-9389

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

Section I-9389 - Content

A. The medical record shall contain the following minimum data:

1. unique patient identification data;

2. admission and discharge dates;

3. complete history and physical examination, in accordance with medical staff policies and procedures;

4. provisional admitting diagnosis and final diagnosis;

5. medical staff orders;

6. progress notes;

7. nursing documentation and care plans;

8. record of all medical care or treatments; and

9. discharge summary.

B. The medical record shall contain the following when applicable:

1. clinical laboratory, pathological, nuclear medicine, radiological and/or diagnostic reports;

2. consultation reports;

3. pre-anesthesia note, anesthesia record, and post-anesthesia notes;

4. operative reports;

5. obstetrical records, including:

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

b. separate infant record containing date and time of birth, condition at birth, sex, weight at birth if condition permits weighing, and condition of infant at time of discharge;

c. autopsy reports; and/or

d. any other reports pertinent to the patient's care.

La. Admin. Code tit. 48, § I-9389

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing LR 21:177 (February 1995), amended LR 29:2415 (November 2003).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2100-2115.