N.M. Admin. Code § 8.370.18.24

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.370.18.24 - PATIENT RECORDS

Each facility licensed pursuant to these regulations must maintain a medical record for each patient. Every record must be accurate, legible and promptly completed. Medical records must include at least the following:

A. Ambulatory surgical centers:

(1) patient identification;

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

(3) preoperative diagnostic studies (entered before surgery), if performed;

(4) findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body;

(5) any allergies and abnormal drug reactions;

(6) entries related to anesthesia administration;

(7) documentation of properly executed informed patient consent; and

(8) discharge diagnosis;

B. Diagnostic and treatment centers, rural health clinics, limited diagnostic and treatment centers:

(1) patient identification;

(2) patient consent forms (if applicable);

(3) pertinent medical history;

(4) assessment of the health status and health care needs of the patient;

(5) brief summary of the episode for which the patient is requiring care;

(6) disposition, and instructions to the patient;

(7) reports of physical examinations, diagnostic and laboratory test results, and consultative findings; and

(8) all physician's orders, reports of treatments and medication and other pertinent information necessary to monitor the patient's progress;

C. Infirmaries:

(1) same as Paragraphs (1) through (8) of Subsection B of 8.370.18.24 NMAC above;

(2) nursing notes (for those patients requiring overnight care or observation); and

(3) medication chart (if applicable);

D. New or innovative outpatient service:

(1) same as Paragraphs (1) through (8) of Subsection B of 8.370.18.24 NMAC above;

(2) any other information deemed necessary by the licensing authority after review and approval of the new or innovative service.

N.M. Admin. Code § 8.370.18.24

Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024