(a) Outpatient records. An outpatient record shall:

1. (1) Be completed for each outpatient; and

2. (2) Include the following:

   1. (A)

(i) History and physical examination of the patient.

1. (ii) Not applicable if for diagnostic services and/or outpatient therapy services;

   1. (B) Orders and reports of:

      1. (i) Diagnostic services; and
      2. (ii) Outpatient therapy services;
   2. (C) Patient's diagnosis and summary of treatment received, recorded by the attending physician;
   3. (D) Documentation of any medications administered;
   4. (E) Progress notes for subsequent clinic visits recorded by applicable disciplines (practitioners);

   5. (F)

      1. (i) Outpatient surgery record requirements.
      2. (ii) See also 20 CAR § 43-113(f), Health Information Services; and
   6. (G) Discharge instructions.

(b) Emergency room records.

1. (1) An emergency room record shall:

   1. (A) Be completed for each patient who presents for treatment at the emergency room; and

   2. (B) Include the following:

      1. (i) Patient identification;
      2. (ii) Date and the following times:

(b) (b) Time physician was notified of patient's presence in the emergency room;

1. (c) (c) Time of physician's arrival if applicable; and

   1. (d) (d) Discharge;

      1. (iii) History (when the injury or onset of symptoms occurred);
      2. (iv) Vital signs;
      3. (v) Nurses' assessment and physical findings;
      4. (vi) Diagnosis;
      5. (vii)

(b) (b) Also, type and amount of local anesthetic, if administered;

1. (viii) Diagnostic reports with specific orders noted;

   1. (ix) Instructions to patients for follow-up care (e.g., do not drive after receiving sedatives, return to physician's office for removal of sutures in one (1) week);

      1. (x) Disposition of case;
      2. (xi) Signature of patient or his or her representative;
      3. (xii) Signed and dated discharge order; and
      4. (xiii) The ambulance record shall be transferred with the patient.

2. (2) Note. Emergency room records shall be completed within twenty-four (24) hours of the patient's visit.

   1. (c) Observation records.

3. (1)

   1. (A) A record of every patient admitted to an observation status shall be maintained.

   2. (B) The observation record shall include, at a minimum:

      1. (i) Patient identification data;
      2. (ii) Physician's diagnosis and therapeutic orders dated and timed;
      3. (iii) History and physical;
      4. (iv) Physician's progress notes, including results of treatment;
      5. (v) Nursing assessment by a registered nurse;
      6. (vi) Nursing observations;
      7. (vii) Results of all diagnostic testing;
      8. (viii) Medication Administration Record;
      9. (ix) Allergies;
      10. (x) Patient education;
      11. (xi) Plan for follow-up treatment; and
      12. (xii) Referrals.

4. (2) Note. Observation records shall be completed on patients who stay less than twenty-four (24) hours.

   1. (d) Psychiatric records. The basic medical record requirements for psychiatric patients shall be the same as for other patient records with the following additions:
5. (1) The identification data shall include the patient's legal status on the face sheet;
6. (2) A proper consent or authority for admission shall be included;

7. (3) A psychiatric evaluation shall be completed by the attending physician within sixty (60) hours of admission that includes the following:

   1. (A) The patient's chief complaints and/or reaction to hospitalization, recorded in patient's own words if possible;

   2. (B) History of present illness including:

      1. (i) Onset; and
      2. (ii) Reason for current admission;
   3. (C) Past history of any psychiatric problems and treatment, including a record of patient's activities (social, education, vocational, interpersonal and family relationships);
   4. (D) Past psychiatric history of patient's family;

   5. (E) Mental status that includes at least:

      1. (i) Attitude and general behavior;
      2. (ii) Affect;
      3. (iii) Stream of mental activity;
      4. (iv) Presence or absence of delusions and hallucinations;
      5. (v) Estimate of intellectual functions;
      6. (vi) Judgment; and
      7. (vii) An assessment of orientation and memory;
   6. (F) Strengths such as knowledge, interests, skills, aptitudes, experience, education, and employment status written in descriptive terms to be used in developing the master treatment plan; and
   7. (G) Diagnostic impressions and recommendations;

8. (4) A history and physical examination shall:

   1. (A) Be documented by a physician; and
   2. (B) Include a neurological examination within twenty-four (24) hours of admission;

9. (5)

   1. (A) Social service records, including report of interviews with patient, family members, and others shall be included for each admission.
   2. (B) Social assessment and plan of care shall be completed within forty-eight (48) hours of admission;
10. (6) Reports of consultation, psychological evaluations, reports of electroencephalograms, dental records, and reports of special studies shall be included in the records when applicable;

11. (7)

    1. (A) An interdisciplinary master treatment plan shall be developed for each patient and included in the medical record within sixty (60) hours of admission.

    2. (B) The treatment plan shall:

       1. (i) Involve all staff who have contact with the patient; and
       2. (ii) Include at a minimum:

(b) (b) Strengths (assets) including skills and interests;

1. (c) (c) Problems both physical and mental that require therapeutic management;

   1. (d)
2. (1) (d)(1) Long-term and short-term goals describing the desired action or behavior to be achieved.

3. (2) (2) Goals shall be:

   1. (A) (A) Relevant;
   2. (B) (B) Observable; and
   3. (C) (C) Measurable;

(h)

1. (1) (h)(1) Nursing assessment and progress notes integrated into the master treatment plan.

2. (2) (2) Reviews and revisions of the nursing plan of care shall be as required under 20 CAR § 43-110, patient care service;

   1. (i) (i) Signatures of all staff involved;

(k) (k) Staff responsibilities;

1. (8) The treatment received by the patient shall be documented in such a manner and with such frequency as to ensure that all active therapeutic efforts such as individual and group psychotherapy, medication therapy, milieu therapy, occupational therapy, industrial or work therapy, nursing care, and other therapeutic interventions are included;

2. (9)

   1. (A) Progress notes shall be recorded by the physician, social worker, and others involved in active treatment modalities at least as often as the patient is seen.
   2. (B) The notes shall contain recommendations for revisions in the treatment plan;
3. (10) Nursing notes shall be written as required under 20 CAR § 43-110, patient care service;
4. (11) The discharge summary shall include a recapitulation of the patient's hospitalization and recommendations from appropriate services concerning follow-up of aftercare as well as a brief summary of the patient's condition on discharge; and
5. (12) The psychiatric diagnosis contained in the final diagnosis and included in the discharge summary shall be written in the terminology of the current American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.