The medical record shall include, at a minimum, the following items (if applicable):
A. Identification information, which include but are not limited to the following:
Name.
1) Address on admission.
1. Medicare.
2. Medi-Cal.
3. Hospital Number
4. Social Security Number.
3) Age.
4) Sex.
5) Marital status.
6) Legal status.
7) Mother’s Maiden name
· Patient’s Mother’s maiden name
· Place of Birth
8) Legal Authorization for admission (if applicable).
9) School Grade, if applicable
10) Religious Preference.
11) Date and time of admission (or arrival for outpatients).
12) Date of time discharge (departure for outpatients).
13) Name, address and telephone number of person or agency responsible for patient.
14) Name of patient's admitting/attending physician.
15) Initial diagnostic impression.
16) Discharge or final diagnosis and disposition.
17) Allergy records.
18) Advance Directives (if applicable).
20) Medical History including, as appropriate: immunization record, screening tests, allergy record, nutritional evaluation, psychiatric, surgical and past medical history, social and family history, and for pediatric patients a neonatal history.
19) Physical examination.
20) Consultation reports.
21) Orders including those for medication, treatment, prescriptions, diet orders, lab, radiology and other ancillary services.
22) Progress notes including current or working diagnosis (excluding psychotherapy notes).
23) Nurses' notes, which shall include, but not be limited to, the following:
- Nursing assessment including nutritional, psychosocial and functional assessments.
- Concise and accurate record of nursing care administered.
- Record of pertinent observations including psychosocial and physical manifestations and relevant nursing interpretation of such observations.
- Name, dosage and time of administration of medications and treatment. Route of administration and site of injection shall be recorded if other than by oral administration.
- Record of type of restraint and time of application and removal.
- Record of seclusion and time of application and removal. (NPH)
24) Graphic and vital sign sheet.
25) Results of all laboratory tests performed.
26) Results of all X-ray examinations performed.
27) Consent forms for care, treatment and research, when applicable.
28) Problem List (outpatient records only).
29) Emergency Department record.
30) Anesthesia record including preoperative diagnosis, if anesthesia has been administered.
31) Operative and procedures report including preoperative and postoperative diagnosis, description of findings, technique used, and tissue removed or altered, if surgery was performed.
32) Pathology report, if tissue or body fluid was removed.
33) Written record of preoperative and postoperative instructions.
34) Labor record, if applicable.
35) Delivery record, if applicable.
36) Physical, Occupational and/or respiratory therapy assessments and treatment records, when applicable.
37) Patient/Family Education Plan (NPH Only)
38) Clinical Data set from other providers.
39) Master Data Sets (as applicable to record type) including but not limited to : MDS (Skilled Nursing), OASIS (Home Health), IRF and PAI (Rehabilitation).
40) Patient Photographs when used for identification or treatment.
41) Master Treatment Plan and Reassessment (NPH only).
42) Discharge Instructions
43) A discharge summary which shall briefly recapitulate the significant findings and events of the patient's hospitalization, final diagnoses, his/her condition on discharge and the recommendations and arrangements for future care. If applicable it shall include diet and self-care instructions.
44) Copies of letters to patients.
45) Email communications between the patients and the provider regarding the care and treatment of the patient.
46) Telephone Encounters. Documentation is required for telephone encounters with patients and/or their caregivers, or other care providers that:
1. Provide new or renewal of prescription for medications
2. Alter the current plan of care, including treatments and medications
3. Identify a new system or problem and provide a plan of care
4. Provide home care advice for symptom/problem management
5. Provide authorization for care
6. Provides or reinforces patient education
Documentation should include the date and time of call, name of caller and relationship to patient (if different from patient), date and time of the response (or attempts to return call), the response given, and the signature and professional title of provider or clinic staff handling the call.
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