1. (a) Reports shall be made by each hospital to the appropriate agency, including but not limited to the following:

   1. (1) Communicable disease.
   2. (2) Births and deaths.
   3. (3) Periodic reports to the Department on forms supplied for this purpose.
   4. (4) Newborn hearing screening. The hospital shall proceed pursuant to 310:540-1-3 (relating to newborn hearing screening).

   5. (5) Newborn metabolic disorder screening.

      1. (A) Testing of newborns. The hospital shall proceed pursuant to 310:550-3-1 (relating to newborn metabolic disorder screening).
      2. (B) Blood specimen collection for hospital births. The hospital shall proceed pursuant to 310:550-5-1 (relating to newborn metabolic disorder screening).
      3. (C) Pulse oximetry screening for birthing hospitals. The hospital shall proceed pursuant to 310:550-5-2 (relating to pulse oximetry screening).
      4. (D) Screening for premature/sick infants. The hospital shall proceed to 310:550-5-1 (relating to newborn metabolic disorder screening).
      5. (E) Newborn screening hospital recording. The hospital shall proceed pursuant to 310:550-7-1 (relating to newborn metabolic disorder screening).
      6. (F) Pulse oximetry screening hospital recording. The hospital shall proceed pursuant to 310:550-7-1 (relating to newborn pulse oximetry screening).
      7. (G) Parent, guardian and health care provider education. The hospital shall proceed pursuant to 310:550-13-1 (relating to newborn disorder screening).
      8. (H) Training. The hospital shall proceed pursuant to 310:550-13-1 (relating to newborn disorder screening).
   6. (6) Birth defects. Each hospital shall have the capability of producing a list of patients up to six (6) years of age who have been diagnosed with a birth defect(s), and all women discharged with a diagnosis of stillbirth, miscarriage, or poor reproductive outcome. On request, each hospital shall make the medical records of these individuals available to the State Department of Health.
   7. (7) Abortions. Attending physicians shall complete and submit to the Department a report form for each abortion performed or induced as required by 63 O.S. 1999, Section 1-738.

2. (b) Record of patient admission.

   1. (1) All persons admitted to any institution covered by these standards shall be under the care of a doctor of medicine (M.D.) or osteopathy (D.O.) duly licensed to practice medicine and surgery in the State of Oklahoma or a licensed independent practitioner, whose name shall be shown on the admitting record.

   2. (2) The hospital admitting record also shall show the following for each patient.

      1. (A) Full name of patient with age, sex, address, marital status, birth date, home phone number, date of admission, and admitting diagnosis.
      2. (B) Next of kin, with address, phone number, and relationship.
      3. (C) Date and time of admission, the admission and final diagnoses, and the name of physician or licensed independent practitioner.
      4. (D) Any advanced directive for health care as defined in the Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act.

   3. (3) Special clinical reports shall be kept, including the following:

      1. (A) Obstetrical patients throughout labor, delivery, and post-partum.
      2. (B) Newborn, giving the infant's weight, length, and other notes relative to physical examination.
      3. (C) Surgical and operative procedures, including pathological reports.
      4. (D) Record of anesthesia administration.

3. (c) Orders for medications, treatments, and tests.

   1. (1) All medication orders shall be written in ink and signed by the ordering physician or practitioner authorized by law to order the medication, with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician- approved hospital policy after an assessment for contraindications. The order shall be preserved on the patient's chart.
   2. (2) All orders shall be written in ink and signed by the ordering physician or practitioner. Orders received by resident physicians shall be co-signed if required by medical staff bylaws. The order shall be preserved on the patient's chart.
   3. (3) All orders taken from the physician or practitioner, for entry by persons other than the physician or practitioner, shall be countersigned.
   4. (4) Telephone or verbal orders may be authenticated by an authorized physician or practitioner other than the ordering physician or practitioner when this practice is defined and approved in the medical staff bylaws. If allowed, medical staff bylaws must identify the physicians or practitioners who may authenticate another physician's or practitioner's telephone or verbal order, e.g. physician partners or attending physicians or practitioners, and define the circumstances under which this practice is allowed. The bylaws must also specify that when a covering or attending physician or practitioner authenticates the ordering physician's or practitioner's telephone or verbal order, such an authentication indicates that the covering or attending physician or practitioner assumes responsibility for his or her colleague's order and verifies the order is complete, accurate, appropriate, and final. The person taking the telephone or verbal order shall read the order back to the physician or practitioner to ensure it was correctly understood and verify on the order the fact that the order was read back. Each facility, within its own procedures and protocols, shall establish a verification process to be placed on orders to demonstrate that the order was read back to the physician.

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

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

Amended at 18 Ok Reg 2032, eff 6-11-01

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

Amended at 24 Ok Reg 1189, eff 4-2-07 (emergency)

Amended at 25 Ok Reg 2472, eff 7-11-08

Amended at 30 Ok Reg 1966, eff 7-25-13

Amended at 31 Ok Reg 1619, eff 9-12-14

Amended at 36 Ok Reg 1730, eff 9-13-19

Amended at 38 Ok Reg 2066, eff 9-11-21