(a)

1. (1) A medical record shall be maintained for each patient of the in vitro fertilization facility.
2. (2) All these records must be kept separate from the other regular records of the facility.
3. (3) The original or a copy of the original (when the original is not available) of all reports shall be filed in the medical record.

4. (4) The record shall be:

   1. (A) Permanent; and
   2. (B) Either typewritten or legibly written in ink.
5. (5) All dictated reports shall include the date of dictation and the date of transcription.

6. (6)

   1. (A) Only standard abbreviations, approved by the staff of the facility, shall be used.
   2. (B) This list of abbreviations shall be:

(i) Reviewed annually; and

1. (ii) Revised if necessary.

(b) Medical orders. All medical orders (medication, treatments, tests, and procedures) shall be in writing and shall be signed by the physician.

1. (c) Confidentiality.
2. (1) Medical records shall be considered confidential.
3. (2) Only authorized personnel shall have access to the medical records.

4. (3)

   1. (A) All medical records shall be secured at all times.
   2. (B) If authorized personnel are not present, the records shall be locked.

5. (4) Records shall be available to authorized personnel from the Department of Health.

   1. (d) Consent for procedures. A specific consent for procedures shall:
6. (1) Be documented prior to the procedure to be performed; and

7. (2) Include the:

   1. (A) Date;
   2. (B) Time; and

   3. (C) Signatures of:

      1. (i) The patient;
      2. (ii) The physician; and
      3. (iii) A witness.

(f) Anesthesia. When anesthesia is utilized, with or without loss of consciousness, a complete anesthesia report, including pre-evaluation and post-follow-up shall be documented by the:

1. (1) Anesthesiologist and/or the certified registered nurse anesthesiologist (CRNA); or
2. (2) Physician who administered the anesthesia.

(g) Procedure report.

1. (1) An individualized procedure report shall be:

   1. (A) Written or dictated by the physician immediately following the procedure; and
   2. (B) Signed within seventy-two (72) hours.

2. (2) The report shall describe, in detail:

   1. (A) Techniques;
   2. (B) Findings;
   3. (C) Pre-procedural and post-procedural diagnosis; and
   4. (D) Other pertinent information.

(h) The record of the patient shall also include:

1. (1) Orders and reports of diagnostic services;
2. (2) Documentation of any medication administered; and
3. (3) Progress notes for subsequent clinic visits recorded by applicable disciplines.