Ala. Admin. Code r. 420-5-18-.05

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-18-.05 - Patient Evaluation

(1)Outside Information. Any available outside information must be properly obtained with suitable releases. The receipt of this information by the facility must be reflected in the patient's chart.

(2)Medical and Sleep History, Physical Examination, Laboratory Tests. Evidence of a recent general clinical work-up obtained sleep evaluation must be contained in the chart, as well as evidence that this information was reviewed by a staff physician prior to testing. Laboratory test results must always be available in the patient records. An evaluation at a sleep disorders facility is a medical evaluation and appropriate medical procedures must be followed.

(3) Consultative Evaluations and Procedures. Sleep disorders require careful and total evaluation. Such evaluation often requires utilization of knowledgeable consultants. Evidence should appear in the charts that appropriate consultants have been consistently utilized. Prompt communications between the facility's professional and technical personnel and consultants is crucial to an integrated clinical effort.

(4) Scoring and Interpretation of Polysomnographic Data. A facility must have evidence that its recordings are adequate and have been properly scored and interpreted. An appropriate technical monitoring log regarding nocturnal patient activity, position, and events must be maintained throughout the night of recording. An oximetry strip chart may be used for this purpose. Scoring may be performed by technologists or staff physician, but interpretation of polysomnograms is the responsibility of the Medical Director or staff physician who must submit a signed and dated report for each separate polysomnographic procedure. In addition, a written and signed assessment of the clinical significance of these results is the role of the physician responsible for the case and must be a component of the patient's chart.

Author:

Ala. Admin. Code r. 420-5-18-.05

New Rule: Filed November 20, 1996; effective December 24, 1996.

Statutory Authority:Code of Ala. 1975, Title 22, Chapter 21.