15 Miss. Code. R. 16-1-42.17.5

Current through October 31, 2024

Rule 15-16-1-42.17.5 - Individual Patient 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. Operative report.

6. Pertinent laboratory, pathology and X-ray reports.

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. 16-1-42.17.5

Miss. Code Ann. § 41-75-13