- (a) All significant clinical information pertaining to a patient shall be incorporated in the patient’s medical record.
- (b) Entries in the record shall be dated and authenticated by the person making the entry.
- (c) Symbols and abbreviations may be used only when they have been approved by the medical staff and when there exists a legend to explain them.
- (d) Oral orders shall include the date and signature of the person recording them. They shall be given and authenticated in accordance with the provisions of § 107.62 (relating to oral orders). All other orders shall be recorded in accordance with the provisions in § § 107.61 and 107.62—107.65 (relating to medical orders).
- (e) A single signature on the face sheet of a record shall not suffice to authenticate the entire record. Each entry shall be individually authenticated.
- (f) Notation of unusual incidents shall be entered in accordance with the provisions of § 109.37 (relating to unusual incidents) and Chapter 151 (relating to fire, safety and disaster services).
- (g) Records of patients discharged shall be completed within 30 days following discharge.
Authority
The provisions of this § 115.33 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 § 115.33 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial page (37838).
Cross References
This section cited in 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).