§ 71549. Medical Record Content.

(a) Each inpatient medical record shall consist of at least the following:

(1) Identification sheets to include but not be limited to the following:

(A) Name.

(B) Address on admission.

(C) Identification number (if applicable).

1. Hospital admission number.

2. Social Security number.

3. Medicare number.

4. Medi-Cal number.

(D) Age.

(E) Sex.

(F) Marital status.

(G) Legal status.

(H) Religion.

(I) Date of admission.

(J) Date of discharge.

(K) Name, address and telephone number of person or agency responsible for patient.

(L) Name of patient's medical staff member responsible for care.

(M) Initial diagnostic impression.

(N) Discharge or final diagnosis.

(O) Disposition.

(2) Psychiatric history and physical examination.

(3) Legal authorization for admission.

(4) Consultation reports, including neurologic examination.

(5) Order sheet including medication, treatment and diet orders.

(6) Treatment plan.

(7) Progress notes including current or working diagnosis, the complaints of others regarding the patient, as well as the patient's comments.

(8) Nurses' notes which shall include but not be limited to the following:

(A) Concise and accurate record of nursing care provided.

(B) Record of pertinent observation of the patient and the response to treatment.

(C) Name, dosage and time of administration of medications and treatment. Route of administration and site of injection shall be recorded, if other than by oral administration.

(D) Record of type of restraint, including time of application and removal.

(9) Vital sign sheet, including weight record.

(10) Reports of all laboratory tests performed.

(11) Reports of all X-ray examinations performed.

(12) Consent forms, when applicable.

(13) Anesthesia record including preoperative diagnosis, if anesthesia has been administered.

(14) Operative report including preoperative and postoperative diagnosis, description of findings, technique used, tissue removed or altered, if surgery was performed.

(15) Pathological report, if tissue or body fluid was removed.

(16) Labor record, if applicable.

(17) Delivery record, if applicable.

(18) A discharge summary which shall briefly recapitulate the significant findings and events of the patient's hospitalization, the patient's condition on discharge and the recommendation and arrangements for future care.

HISTORY

1. Amendment filed 2-8-83; designated effective 3-2-83 (Register 83, No. 7).

Note

Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Sections 1276 and 1316.5, Health and Safety Code.