Section 7 AAC 13.115 - Patient records(a) A facility shall maintain an organized records system that contains the following for each patient: (1) a description of history, physical findings, and laboratory results for each visit;(2) an assessment and, where appropriate, a diagnosis;(3) a treatment plan; and(4) a record of medications prescribed.(b) Facility staff shall complete a patient record at the time of the visit. The person recording a visit shall sign and date the entry.Eff. 3/17/85, Register 93