3701-83-23.3 Medical records.

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

(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 facility or to a facility for inpatient care, the transferring dialysis facility shall send all requested medical records and information to the receiving facility within one day of the transfer.

Effective: 04/24/2011
R.C. 119.032 review dates: 02/07/2011 and 02/10/2016
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