Cal. Code Regs. tit. 22 § 79349

Current through Register 2024 Notice Reg. No. 52, December 27, 2024

Section 79349 - Patient Health Record Content

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

(1) Identification sheets which shall include but are not limited to the following:

(A) Name.

(B) Address on admission.

(C) Identification number.

(D) Social Security Number.

(E) Medicare identification number, if applicable.

(F) Medi-Cal identification number, if applicable.

(G) Date of birth.

(H) Sex.

(I) Marital status.

(J) Religion.

(K) Date of admission.

(L) Date of discharge.

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

(N) Name of patient's attending physician.

(O) Initial diagnostic impression.

(2) History and physical examination.

(3) Consultation reports, if applicable.

(4) Physician's order sheet including medication and diet orders.

(5) Progress notes which shall include but not be limited to pertinent observations of the patient by the staff responsible for the implementation of the recovery plan.

(6) Records which shall include but not be limited to pertinent observations of the patient by staff responsible for the care of the patient.

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

(8) Signed consent forms including refusal of medication and treatment and authorization for release of information, if requested.

(9) The medical director, or in the medical director's absence, the designated alternate, shall ensure that the responsible attending physician shall complete a discharge summary which shall include:

(A) All final diagnoses, including complications of care, stated in standard medical terminology without abbreviations;

(B) All procedures performed;

(C) A brief recapitulation of the significant findings and events of the patient's hospitalization;

(D) A critical evaluation of the patient's progress in attaining the goals of their individual recovery plan;

(E) Condition on discharge;

(F) Instructions and arrangements for aftercare;

(G) Discharge medications, if any.

(10) A copy of the transfer information shall be retained in the health record.

(11) Upon discharge, the individual recovery plan shall be retained in the patient's health record.

Cal. Code Regs. Tit. 22, § 79349

1. Editorial correction of subsection (a)(5) filed 12-15-82 (Register 82, No. 51).

Note: Authority cited: Sections 208(a), 1275 and 1275.2, Health and Safety Code. Reference: Sections 1250.3 and 1275.2, Health and Safety Code.

1. Editorial correction of subsection (a)(5) filed 12-15-82 (Register 82, No. 51).