1. (1) An individual clinical record must be established for each person receiving care. Each record must be accurate, legible, and promptly completed. The record must include at least the following:

   1. (a) patient identification including the patient's full name, sex, address, date of birth, and next of kin (for minor patients) or emergency contact (for adult patients);
   2. (b) admitting diagnosis;
   3. (c) significant medical history and results of physical examination;
   4. (d) anesthesia reports;
   5. (e) procedure reports;
   6. (f) pertinent laboratory and pathology reports as indicated and tests for RH Negative factor. A pregnancy test or pathological exam of tissue shall be recorded to verify pregnancy;
   7. (g) nurses' notes including admission, preoperative, and recovery;
   8. (h) preoperative and postoperative orders;
   9. (i) any allergies and abnormal drug reactions;
   10. (j) discharge note, discharge diagnosis, and instructions given to the patient;
   11. (k) documentation of properly executed informed patient consent which includes notice of transfer when deemed appropriate; and

   12. (l) documentation:

       1. (i) that the patient was provided a hotline telephone number for women who are coerced into an abortion or who are victims of rape, incest, or sex trafficking;
       2. (ii) of the assistance provided to the patient if abortion clinic staff suspect the patient may be coerced into an abortion or may be the victim of rape, incest, or sex trafficking; and
       3. (iii) of compliance with any applicable mandatory reporting requirements with respect to the patient.
2. (2) To ensure confidentiality, security, and physical safety of a patient's medical record, the abortion clinic must designate a person to oversee and manage the clinical records.

3. (3) The abortion clinic must have policies concerning clinical records. The policies must include:

   1. (a) the retention of active records;
   2. (b) the retirement of inactive records;
   3. (c) the timely entry of data in records; and
   4. (d) the release of information contained in records.

Authorizing statute(s): 50-20-903, MCA

Implementing statute(s): 50-20-903, MCA

History: NEW, 2024 MAR p. 2242, Eff. 9/21/24.