Each patient medical record required by paragraph (A) of rule 3701-83-11 of the Administrative Code shall contain at least the following information:
(A) Patient information including:
(1) Name, address, date of birth, gender, and race or ethnicity;
(2) History and physical examination data including allergies, current medications, past adverse drug reactions, and family medical history;
(3) Diagnosis; and
(4) Dialysis prescriptions.
(B) Treatment data including;
(1) A written individualized comprehensive patient care plan;
(2) Progress notes; and
(3) Treatment notes including dates and times the patient was on or off dialysis, pre-dialysis safety checks, vital signs monitoring during dialysis, and notations of adverse reactions.
(C) Medication administration.
(D) Any special examination or report, including x-ray, laboratory, or pathology report.
(E) Signed consent for treatment form.
(F) Documentation indicating that the patient or patient's representative received in writing the following:
(1) Information on complaint policies and grievance procedures;
(2) Information regarding the center's policy on advanced directives and do-not-resuscitate orders, if applicable; and
(3) Information about the services to be performed.
(G) Documentation indicating that the patient or patient's representative received information about:
(1) Emergency self disconnect; and
(2) Measures to be taken in the event of an at home post-treatment medical emergency.
(H) Discharge data including, condition upon discharge, and post-discharge care and instructions.
(I) When a dialysis patient is transferred to another dialysis center or to a facility for inpatient care, the transferring dialysis center shall send all requested medical records and information to the receiving dialysis center or facility within one day of the transfer.
Five Year Review (FYR) Dates: 02/16/2016 and 02/15/2021
Promulgated Under: 119.03
Statutory Authority: 3702.13, 3702.30
Rule Amplifies: 3702.12, 3702.13, 3702.30
Prior Effective Dates: 9/5/2002, 6/29/09, 4/24/11