23 Miss. Code. R. 210-1.7

Current through December 10, 2024

Rule 23-210-1.7 - Documentation Requirements

The physician and ASC must maintain auditable records that will substantiate the services provided. The ASC must maintain a medical record for each patient. 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 tissues 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, and

H. Discharge diagnosis and instructions.

23 Miss. Code. R. 210-1.7

Miss. Code Ann. § 43-13-121; 42 CFR § 416