- A. The facility shall comply with COMAR 10.05.01.09 and the requirements of this regulation.
B. Each medical record shall include, at a minimum:
- (1) Preoperative diagnostic studies, entered before surgery, if performed;
- (2) Findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those tissues exempted by the medical director;
- (3) Any allergies and abnormal drug reactions; and
- (4) Entries related to anesthesia administration.
Authority: Health-General Article, §19-3B-01 et seq., Annotated Code of Maryland
Effective date: August 23, 1999 (26:17 Md. R. 1322)
Regulation .01B amended effective March 14, 2016 (43:5 Md. R. 385)
Regulation .03 amended effective August 19, 2013 (40:16 Md. R. 1343); December 21, 2015 (42:25 Md. R. 1542)