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;
   2. (b) significant medical history and results of physical examination;
   3. (c) preoperative diagnostic studies, if performed;
   4. (d) findings and techniques of the operation including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body;
   5. (e) any allergies and abnormal drug reactions;
   6. (f) entries related to anesthesia administration;
   7. (g) documentation of properly executed informed patient consent which includes notice of transfer when deemed appropriate;
   8. (h) discharge diagnosis; and
   9. (i) discharge recommendations and instructions given to the patient.
2. (2) To ensure confidentiality, security, and physical safety of a patient's medical record, the outpatient center must designate a person to oversee and manage the clinical records.

3. (3) The outpatient center 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): 50-5-103, MCA

Implementing statute(s): 50-5-103, MCA

History: NEW, 2013 MAR p. 1626, Eff. 9/6/13.