1. (a) Complete medical records shall be kept on every patient seen and/or treated in the emergency room and shall contain as a minimum the following:

   1. (1) Patient identification.
   2. (2) Time and means of arrival.
   3. (3) History of disease or injury.
   4. (4) Physical findings.
   5. (5) Laboratory and x-ray reports, if any.
   6. (6) Diagnosis and therapeutic orders.
   7. (7) Record of treatment, including vital signs.
   8. (8) Disposition of the case.
   9. (9) Signature of the registered nurse.
   10. (10) Signature of the licensed independent practitioner, if applicable.
   11. (11) Signature of the physician, if applicable.
   12. (12) Documentation if patient left against medical advice.
2. (b) Medical records for patients seen and/or treated in the emergency room shall be organized and filed by the medical records department.
3. (c) Where appropriate, medical records of emergency services shall be integrated with those of the inpatient and outpatient services.
4. (d) Emergency medical records shall be kept, as a minimum, as required by state and federal statutes.

Added at 12 Ok Reg 1555, eff 4-12-95 (emergency)

Added at 12 Ok Reg 2429, eff 6-26-95

Amended at 20 Ok Reg 1664, eff 6-12-03