1. (a) The medical record shall contain sufficient information to justify the diagnosis, verify the treatment and document the course of treatment and results accurately.

2. (b) All in-patient records shall include the following information:

   1. (1) identification data (name, address, age, sex) and, when the identification data is not obtainable, the reason for such;
   2. (2) date and time of admission and discharge;

   3. (3) medical history:

      1. (A) chief complaint;
      2. (B) details of the present illness;
      3. (C) relevant past, social, and family histories; and
      4. (D) reports of relevant physical examinations;
   4. (4) diagnostic and therapeutic orders;
   5. (5) reports of procedures, tests and their results;
   6. (6) provisional or admitting diagnosis;
   7. (7) evidence of appropriate informed consent or a written statement explaining why consent was not obtained;
   8. (8) clinical observations, including results of therapy;
   9. (9) record of medication and treatment administration;
   10. (10) progress notes of all disciplines;
   11. (11) conclusions at termination of hospitalization or evaluation and treatment;
   12. (12) all relevant diagnosis established by the time of discharge;
   13. (13) consultation reports;
   14. (14) surgical record, including anesthesia record, pre-operative diagnosis, surgeon's operative report and post-operative orders and any instructions given to the patient or family; and
   15. (15) autopsy findings, if performed.

History Note: Authority G.S. 131E-79;
Eff. January 1, 1996;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017.