Alaska Admin. Code tit. 7, § 13.115 – Patient records

(a) A facility shall maintain an organized records system that contains the following for each patient:
1. (1) a description of history, physical findings, and laboratory results for each visit;
2. (2) an assessment and, where appropriate, a diagnosis;
3. (3) a treatment plan; and
4. (4) a record of medications prescribed.
(b) Facility staff shall complete a patient record at the time of the visit. The person recording a visit shall sign and date the entry.

(Eff. 3/17/85, Register 93)

Authority: AS 18.25.100