16 Del. Admin. Code § 3335-6.0

Current through Register Vol. 28, No. 7, January 1, 2025

Section 3335-6.0 - Medical Record

6.1 A legible, comprehensive and accurate medical record must be maintained for each patient evaluated or treated.

6.2 The medical record must include:

6.2.1 Patient identifying information;

6.2.2 Patient's medical history and a physical examination:

6.2.2.1 Inclusive of the cardiorespiratory system and other systems related to the diagnosis;

6.2.2.2 Completed within 30 days prior to the procedure;

6.2.3 Diagnosis and plan of care;

6.2.4 Appropriate diagnostic reports;

6.2.5 Informed consent;

6.2.6 Documentation of the time-out;

6.2.7 Operative/procedure report;

6.2.8 Pathology reports, if applicable;

6.2.9 Outcome and follow-up plans;

6.2.10 A separate anesthesia record for each administration of anesthesia which must include:

6.2.10.1 Type of anesthesia;

6.2.10.2 Drug type, dose and route;

6.2.10.3 Time of administration;

6.2.10.4 Fluids administered;

6.2.10.5 Patient weight;

6.2.10.6 Vital signs monitoring;

6.2.10.7 Estimated blood loss;

6.2.10.8 Duration of procedure; and

6.2.10.9 Any complication or unusual event related to the procedure or anesthesia.

6.2.11 Intra-procedure and post-procedure monitoring.

6.3 The facility must ensure the security and confidentiality of the medical record in accordance with state and federal laws.

16 Del. Admin. Code § 3335-6.0

23 DE Reg. 125( 8/1/2019) (final)