15 Miss. Code. R. 16-1-44.19.4

Current through December 10, 2024

Rule 15-16-1-44.19.4 - Preservation of Records

Each patient's medical record shall include at least the following information:

1. Patient identification, including the patient's full name, sex, address, date of birth, next of kin, and patient number.

2. Admitting diagnosis.

3. Preoperative history and physical examination pertaining to the procedure to be performed.

4. Anesthesia reports.

5. Procedure report.

6. Pertinent laboratory and pathology reports as indicated and tests for RH Negative factor. A pregnancy test or pathological exam of tissue shall be recorded to verify pregnancy.

7. Preoperative and postoperative orders.

8. Discharge note and discharge diagnosis.

9. Informed consent.

10. Nurses' notes:

a. Admission and preoperative.

b. Recovery and discharge.

15 Miss. Code. R. 16-1-44.19.4

Miss. Code Ann. § 41-75-13