- (a) a history, physical examination, pertinent preoperative diagnostic studies and a preoperative diagnosis incorporated into the medical record prior to surgery;
- (b) a record of any allergies and abnormal drug reactions;
- (c) evidence of the appropriate written informed consent for surgery;
- (d) preoperative and post-operative instructions;
- (e) anesthesia record;
- (f) an operative report describing surgical procedures performed and findings, completed by the individual performing the operation;
- (g) post-operative follow-up report, including any post-operative abnormalities or complications;
- (h) pathology reports on anatomical parts and tissues removed during surgery;
- (i) a discharge diagnosis; and
- (j) follow-up plans.
In addition to the requirements of section 751.7 of this Title, the medical record shall contain the following information: