Okla. Admin. Code § 310:667-19-8

Current through Vol. 42, No. 6, December 2, 2024

Section 310:667-19-8 - Content

(a) The medical record shall contain sufficient information to justify the diagnosis and warrant the treatment provided. The medical record shall contain the following information:

(1) Identification data. Identification data shall include at least the patient's name, address, age and date of birth, sex, and marital status.

(2) Date of admission.

(3) Date of discharge.

(4) Chief complaint. The chief complaint shall consist of a concise statement describing the reason the patient is seeking medical attention.

(5) History of present illness. The history of the present illness shall include a detailed description of the patient's symptoms including:

(A) Location of pain;

(B) Quality of pain and symptoms;

(C) Severity;

(D) Timing;

(E) Duration;

(F) Modifying factors, i.e., things that worsen or alleviate symptoms; and

(G) Associated signs and symptoms.

(6) Past history. The past history shall include all previous illnesses and previous surgical procedures.

(7) Medication history. The medication history shall list all current medications and all know drug reactions/allergies.

(8) Social history. The social history shall include a description of the patient's social setting and use of tobacco and/or alcohol, illicit drugs, and work history.

(9) Family history. The family history shall include a description of the state of health of living first-degree relatives, and causes of death of first-degree relatives.

(10) Review of systems. Elements of the review of systems shall include:

(A) General overall condition (fever, weight loss, stamina, etc.);

(B) Head, eyes, ears, nose, throat;

(C) Cardiovascular;

(D) Respiratory;

(E) Breasts;

(F) Gastrointestinal;

(G) Genitourinary;

(H) Musculoskeletal;

(I) Skin and lymphatics;

(J) Neurological;

(K) Psychiatric;

(L) Hematologic;

(M) Allergic; and

(N) Immunologic.

(11) Physical examination. The physical examination shall include a record of the patient's vital signs at the time of the examination including height, weight, blood pressure, temperature, pulse rate, and respiratory rate. Negative findings for a system may be indicated in the record of the physical examination by the lack of an entry for that system. If the hospital allows negative findings for a system on physical examination to be documented by omission of an entry for that system, medical records policies and procedures shall specify whether the omission of an entry signifies the system was examined and no significant findings were noted or that no examination of that system was performed. Specific abnormal or pertinent negative findings of the examination of the affected or symptomatic body area(s) must be documented in regards to the following areas:

(A) Head, eyes, ears, nose, and throat;

(B) Neck;

(C) Chest, including lungs, breasts, and axilla;

(D) Cardiovascular, including peripheral pulses, and examination of abdominal aorta;

(E) Abdomen;

(F) Genitourinary;

(G) Hematologic and Immunologic;

(H) Musculoskeletal;

(I) Neurological;

(J) Psychiatric; and

(K) Skin and lymphatics.

(12) Provisional diagnosis which shall be an impression (diagnosis) reflecting the examining physician's or licensed independent practitioner's evaluation of the patient's condition and shall be based mainly upon physical findings and history.

(13) Special examinations, if any, such as clinical laboratory reports, diagnostic imaging studies, consultation reports, etc. Consultation reports shall be a written opinion and shall be signed by the consultant, including his or her findings from the history and physical examination of the patient.

(14) Treatment and medication orders.

(15) Diagnostic and medical procedure reports.

(16) Surgical records including anesthesia record, preoperative diagnosis, operative procedure and findings, postoperative diagnosis, and tissue diagnosis on all specimens examined. Tissue reports shall include a report of microscopic findings if hospital regulations require that microscopic examination be done. If only gross examination is warranted, a statement that the tissue has been received and a gross description shall be made by the laboratory and filed in the medical record.

(17) Progress and nursing notes shall give a chronological picture of the patient's progress and shall be sufficient to delineate the course and results of treatment. The condition of the patient shall determine the frequency with which they are made.

(18) Record of temperature, pulse, respiration, and blood pressure.

(19) Definitive final diagnosis expressed in terminology of a recognized system of disease nomenclature.

(20) Discharge Summary that shall be a recapitulation of the significant findings and events of the patient's hospitalization and condition upon discharge, including prescribed medications at time of discharge.

(21) Autopsy findings in a complete protocol shall be filed in the record when an autopsy is performed.

(b) Facsimile copies shall be acceptable as any portion of the medical record. If the facsimile is transmitted on thermal paper, that paper shall be photocopied to preserve its integrity in the record. Facsimile copies shall be considered the same as original copies.

Okla. Admin. Code § 310:667-19-8

Added at 12 Ok Reg 1555, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok Reg 1664, eff 6-12-03