10A N.C. Admin. Code 13B.3906

Current through Register Vol. 39, No. 12, December 1, 2024

Section 13B .3906 - CONTENTS

(a) The medical record shall contain sufficient information to justify the diagnosis, verify the treatment and document the course of treatment and results accurately.

(b) All in-patient records shall include the following information:

(1) identification data (name, address, age, sex) and, when the identification data is not obtainable, the reason for such;

(2) date and time of admission and discharge;

(3) medical history:

(A) chief complaint;

(B) details of the present illness;

(C) relevant past, social, and family histories; and

(D) reports of relevant physical examinations;

(4) diagnostic and therapeutic orders;

(5) reports of procedures, tests and their results;

(6) provisional or admitting diagnosis;

(7) evidence of appropriate informed consent or a written statement explaining why consent was not obtained;

(8) clinical observations, including results of therapy;

(9) record of medication and treatment administration;

(10) progress notes of all disciplines;

(11) conclusions at termination of hospitalization or evaluation and treatment;

(12) all relevant diagnosis established by the time of discharge;

(13) consultation reports;

(14) surgical record, including anesthesia record, pre-operative diagnosis, surgeon's operative report and post-operative orders and any instructions given to the patient or family; and

(15) autopsy findings, if performed.

10A N.C. Admin. Code 13B .3906

Authority G.S. 131E-79;
Eff. January 1, 1996;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017.

Authority G.S. 131E-79;
Eff. January 1, 1996.