10-144-125 Me. Code R. § 4.I

Current through 2024-51, December 18, 2024

Section 144-125-4.I - Medical Records

The Ambulatory Surgical Facility must maintain complete, comprehensive and accurate medical records to ensure adequate patient care.

4.I.1. Organization

The Ambulatory Surgical Facility must develop and maintain a system for the proper collection, storage and use of patient records.

4.I.2. Form and Content of Record

The Ambulatory Surgical Facility must maintain a medical record for each patient. Every record must be accurate, legible and promptly completed. Medical records must include at least the following:

a. Patient identification

b. Significant medical history and results of physical examination

c. Pre-operative diagnostic studies (entered before surgery, if performed).

d. Findings and techniques of the operation, including a pathologist's report on all times removed during surgery, except those exempted by the governing body

e. Any allergies and abnormal drug reactions

f. Entries related to anesthesia administration

g. Documentation of properly executed informed patient consent

h. Discharge diagnosis.

10-144 C.M.R. ch. 125, § 4.I