The medical record contains information that reflects the patient's care, treatment, and serv...

(1)

The medical record contains the following demographic information for the patient: - Name, address, and date of birth and the name of any legally authorized representative - Sex - Legal status of any patient receiving behavioral health care services - Communication needs, including preferred language for discussing health care - Race and ethnicity Note: If the patient is a minor, is incapacitated, or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision-maker, or legally authorized representative are documented in the medical record.

(2)

The medical record contains the following clinical information: - Admitting diagnosis - Any emergency care, treatment, and services provided to the patient before their arrival - Any allergies to food and medications - Any findings of assessments and reassessments - Results of all consultative evaluations of the patient and findings by clinical and other staff involved in the care of the patient - Treatment goals, plan of care, and revisions to the plan of care - Documentation of complications, health care–acquired infections, and adverse reactions to drugs and anesthesia - All practitioners' orders - Nursing notes, reports of treatment, laboratory reports, vital signs, and other information necessary to monitor the patient's condition - Medication records, including the strength, dose, route, date and time of administration, access site for medication, administration devices used, and rate of administration Note: When rapid titration of a medication is necessary, the hospital defines in policy the urgent/emergent situations in which block charting would be an acceptable form of documentation. For the definition and a further explanation of block charting, refer to the Glossary. - Administration of each self-administered medication, as reported by the patient (or the patient’s caregiver or support person where appropriate) - Records of radiology and nuclear medicine services, including signed interpretation reports - All care, treatment, and services provided to the patient - Patient’s response to care, treatment, and services - Medical history and physical examination, including any conclusions or impressions drawn from the information - Discharge plan and discharge planning evaluation - Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care, including any medications dispensed or prescribed on discharge - Any diagnoses or conditions established during the patient’s course of care, treatment, and services Note: Medical records are completed within 30 days following discharge, including final diagnosis.

(3)

The medical record contains any informed consent, when required by hospital policy or federal or state law or regulation. Note: The properly executed informed consent is placed in the patient’s medical record prior to surgery, except in emergencies. A properly executed informed consent contains documentation of a patient’s mutual understanding of and agreement for care, treatment, and services through written signature; electronic signature; or, when a patient is unable to provide a signature, documentation of the verbal agreement by the patient or surrogate decision-maker.

(5)

The hospital uses preprinted and electronic standing orders, order sets, and protocols for patient orders only if the following occurs: - Orders and protocols are reviewed and approved by the medical staff and the hospital's nursing and pharmacy leadership. - Orders and protocols are consistent with nationally recognized and evidence-based guidelines. - Orders and protocols are periodically and regularly reviewed by the medical staff and the hospital's nursing and pharmacy leadership to determine the continuing usefulness and safety of the orders and protocols. - Orders and protocols are dated, timed, and authenticated promptly in the patient's medical record by the ordering practitioner or by another practitioner responsible for the care of the patient only if such a practitioner is acting in accordance with state law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.

(6)

The medical history and physical examination or updates to the medical history and physical examination are placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

(7)

An assessment of the patient (in lieu of a medical history and physical examination as described in 42 CFR 482.24(c)(4)(i)(A) and (B)) is completed and documented after registration, but prior to surgery or a procedure requiring anesthesia services, when the following conditions are met: - The patient is receiving specific outpatient surgical or procedural services. - The medical staff has chosen to develop and maintain a policy that identifies, in accordance with the requirements at 42 CFR 482.22(c)(5)(v), specific patients as not requiring a comprehensive medical history and physical examination, or any update to it, prior to specific outpatient surgical or procedural services.