Current through Register Vol. 54, No. 24, June 15, 2024
(a) Entries in the record shall be dated and authenticated by the person making the entry.(b) Symbols and abbreviations may be used only when they have been approved by the medical staff and when a legend exists to explain them.(c) A single signature on the fact sheet of a record does not suffice to authenticate the entire record. Each entry shall be individually authenticated.(d) Notation of unusual incidents shall be entered in the medical record.(e) Necessary documentation on the patient's medical record as specified in § 563.12 (relating to form and content of record) shall be completed in a timely manner not to exceed 30 days.The provisions of this § 563.13 amended October 22, 1999, effective 11/22/1999, 29 Pa.B. 5583.