3701-83-21 Medical records.

Each ASF medical record shall contain at least the following information as applicable for the surgery to be performed:

(A) Admission data:

(1) Name, address, date of birth, gender, and race or ethnicity;

(2) Date and time of admission; and

(3) Pre-operative diagnosis, which shall be recorded prior to or at the time of admission.

(B) History and physical examination data:

(1) Personal medical history, including but not limited to allergies, current medications and past adverse drug reactions;

(2) Family medical history; and

(3) Physical examination.

(C) Treatment data:

(1) Physician’s, podiatrist’s or dentist’s orders;

(2) Physician’s podiatrist’s or dentist’s notes;

(3) Physician assistant’s notes, if applicable;

(4) Nurse’s notes;

(5) Medications;

(6) Temperature, pulse, and respiration;

(7) Any special examination or report, including but not limited to, x-ray, laboratory, or pathology reports;

(8) Signed informed consent form;

(9) Evidence of advanced directives, if applicable;

(10) Operative record;

(11) Anesthesia record, if applicable; and

(12) Consultation record, if applicable.

(D) Discharge data:

(1) Final diagnosis;

(2) Procedures and surgeries performed;

(3) Condition upon discharge;

(4) Post-treatment care and instructions; and

(5) Attending physician’s, podiatrist’s or dentist’s signature.

(E) Other information required by law.

R.C. 119.032 review dates: 02/28/2006 and 02/28/2011

Promulgated Under: 119.03

Statutory Authority: 3702.13, 3702.30

Rule Amplifies: 3702.12, 3702.13, 3702.30

Prior Effective Dates: 1/13/1996, 9/5/2002