410 Ind. Admin. Code 26.5-8-2

Current through May 29, 2024

Section 410 IAC 26.5-8-2 - Content of the medical record

Authority: IC 16-21-1-7; IC 16-21-2-2.5

Affected: IC 16-21-1; IC 16-21-2; IC 16-34-2-1; IC 16-34-2-1.1

Sec. 2.

(a) The medical record for drug induced abortions must be accurate and contain sufficient information to do the following:

(1) Identify the patient to include name, age, and address.

(2) Document the following:

(A) Tests, examinations, and procedures performed.

(B) The course of the patient's stay in the clinic and the results.

(C) Evidence that the patient was provided the hotline telephone number for assistance to patients who are:

(i) coerced into an abortion; or

(ii) victims of sex trafficking.

(D) Evidence of appropriate informed consent for procedures and treatments as required by IC 16-34-2-1.1.

(E) Any report filed with a state agency or law enforcement agency pursuant to a statutory reporting requirement.

(b) Entries in the medical record must be as follows:

(1) Legible.

(2) Complete.

(3) Made by authorized individuals as specified in clinic and medical staff policies.

(4) Authenticated and dated in accordance with this article.

(c) Patient records for drug induced abortions must document and contain, at a minimum, the following:

(1) Appropriate medical history.

(2) Results of the following:

(A) A physical examination.

(B) Diagnostic or laboratory studies, or both (if performed).

(3) Any allergies and abnormal drug reactions.

(4) Authentication of entries by the physician or physicians and health care workers who treated or cared for the patient.

(5) A copy of the following:

(A) The transfer form if the patient was referred to a hospital or other facility.

(B) The terminated pregnancy report filed with the department.

(C) Any document signed by the patient.

(D) The signed patient agreement form and the signed physician's agreement form required by the manufacturer as required by IC 16-34-2-1(a)(1).

(6) Any report filed with a state agency or law enforcement agency pursuant to a statutory reporting requirement.

410 IAC 26.5-8-2

Indiana State Department of Health; 410 IAC 26.5-8-2; filed 9/6/2019, 3:31 p.m.: 20191002-IR-410190163FRA