POLICIES AND PROCEDURES FORPATIENT MEDICAL RECORDS

1. (a) An adequate medical record shall be maintained for every inpatient, outpatient and patient treated or examined in the emergency unit. This record shall contain data from all episodes of care and treatment of the patient whether services were performed on an inpatient basis, on an outpatient basis, or in the emergency unit. The unit record system should be used whenever feasible. When it is not feasible or appropriate to combine all inpatient, outpatient and emergency records of an individual patient into a unitary record, a system shall be established to:

   1. (1) Assemble, when necessary, all divergently located record components when an inpatient is admitted to the hospital or appears for a prescheduled outpatient appointment.
   2. (2) Require placing copies of pertinent portions of an inpatient’s medical record, such as the discharge resume, the operative note and the pathology report, in the outpatient or combined outpatient/emergency unit record file.
2. (b) A patient’s medical records shall be complete, readily accessible and available to the professional staff concerned with the care and treatment of the patient.

Authority

The provisions of this § 115.31 issued under 67 Pa.C.S. § § 6101—6104; and Reorganization Plan No. 2 of 1973 (71 P. S. § 755-2).

Source

The provisions of this § 115.31 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial page (37836).

Cross References

This section cited in 28 Pa. Code § 117.43 (relating to medical records); 28 Pa. Code § 119.24 (relating to patient medical records); 28 Pa. Code § 135.13 (relating to patient’s medical record; preoperative procedures); and 49 Pa. Code § 16.95 (relating to medical records).