Mont. Admin. r. 37.106.3107

Current through Register Vol. 23, December 6, 2024

Rule 37.106.3107 - MINIMUM STANDARDS FOR ABORTION CLINICS: PATIENT FILES

(1) An individual clinical record must be established for each person receiving care. Each record must be accurate, legible, and promptly completed. The record must include at least the following:

(a) patient identification including the patient's full name, sex, address, date of birth, and next of kin (for minor patients) or emergency contact (for adult patients);

(b) admitting diagnosis;

(c) significant medical history and results of physical examination;

(d) anesthesia reports;

(e) procedure reports;

(f) pertinent laboratory and pathology reports as indicated and tests for RH Negative factor. A pregnancy test or pathological exam of tissue shall be recorded to verify pregnancy;

(g) nurses' notes including admission, preoperative, and recovery;

(h) preoperative and postoperative orders;

(i) any allergies and abnormal drug reactions;

(j) discharge note, discharge diagnosis, and instructions given to the patient;

(k) documentation of properly executed informed patient consent which includes notice of transfer when deemed appropriate; and

(l) documentation:

(i) that the patient was provided a hotline telephone number for women who are coerced into an abortion or who are victims of rape, incest, or sex trafficking;

(ii) of the assistance provided to the patient if abortion clinic staff suspect the patient may be coerced into an abortion or may be the victim of rape, incest, or sex trafficking; and

(iii) of compliance with any applicable mandatory reporting requirements with respect to the patient.

(2) To ensure confidentiality, security, and physical safety of a patient's medical record, the abortion clinic must designate a person to oversee and manage the clinical records.

(3) The abortion clinic must have policies concerning clinical records. The policies must include:

(a) the retention of active records;

(b) the retirement of inactive records;

(c) the timely entry of data in records; and

(d) the release of information contained in records.

Mont. Admin. r. 37.106.3107

NEW, 2024 MAR p. 2242, Eff. 9/21/2024

AUTH: 50-20-903, MCA; IMP: 50-20-903, MCA