(a) A center shall keep a record for each patient who is admitted or accepted for treatment. Patient medical records are the center's property and are subject to the requirements of AS 18.05.042, 7 AAC 105.230, and 7 AAC 105.240. Nothing in this section affects statutes or regulations that govern patient medical record access, use, disclosure, confidentiality, or retention, or maintenance of health information in a patient's record by a health care provider. A center shall maintain the patient's original record or an accurate reproduction of the record's contents in a form that is legible and readily available for not fewer than seven years after the patient is discharged, except that the records of a patient who was a minor at the time the center provided services must be retained until the minor reaches 21 years of age, or seven years after the patient is discharged, whichever is longer. The center shall provide the records to

1. (1) the attending physician, a practitioner responsible for the patient's treatment, a member of the center's medical staff, or a department representative upon request; or
2. (2) another practitioner upon the patient's written request.

(b) Each patient medical record must include, as appropriate,

1. (1) an identification sheet that includes the patient's

   1. (A) name;
   2. (B) medical record number;
   3. (C) address on the date of admission;
   4. (D) date of birth;
   5. (E) sex;
   6. (F) marital status;
   7. (G) religious preference;
   8. (H) dates of service;
   9. (I) parent's, legal guardian's, or other contact person's name, address, and telephone number;
   10. (J) attending physician's name;
   11. (K) initial diagnostic impression;
   12. (L) date of discharge and final diagnosis; and
   13. (M) source of payment;
2. (2) a medical and psychiatric history and examination;
3. (3) consultation reports and special studies reports;
4. (4) a documentation method that includes orders signed by a licensed prescriber;
5. (5) progress notes for each service or treatment received;

6. (6) nurses' notes that must include

   1. (A) an accurate record of care provided;
   2. (B) a record of pertinent observations and response to treatment, including psychosocial and physical manifestations;
   3. (C) an assessment when the center admits the patient;
   4. (D) a discharge plan;
   5. (E) the name and dosage, and the administration date, time, route, and location for each medication or treatment; each administration record entry must include the patient's response and the signature of the person who administered the medication or treatment; and
   6. (F) a record of restraint or seclusion used that includes the duration of each restraint or seclusion;
7. (7) court orders relevant to involuntary treatment;
8. (8) laboratory reports;
9. (9) radiology reports; and
10. (10) consent forms.