§ 115.32. Contents.

 (a)  The medical record shall contain sufficient information to identify the patient clearly, to justify the diagnosis and treatment, and to document the results accurately.

 (b)  If a member of the hospital’s medical staff has performed a physical examination consistent with the medical staff bylaws within 30 days prior to a patient’s admission to the hospital, a reasonably durable, legible copy of the record of this examination may be used in lieu of an admission history and report of physical examination. An interval admission note shall, however, be recorded, including any additions to the history and any subsequent changes in the physical findings.

 (c)  If the patient was admitted to another hospital within 30 days prior to his admission, the medical staff or attending physician shall determine whether to record its own complete history and physical examination. The hospital shall, with the written authorization of the patient, request the records of the previous admission from the other hospital as soon as possible.

 (d)  A medical record shall include notes by authorized house staff members and individuals who have been granted clinical privileges, consultation reports, nurses’ notes and entries by specified professional personnel.

 (e)  A medical record shall include the findings and results of any pathological or clinical laboratory examinations, radiology examinations, medical and surgical treatment, and other diagnostic or therapeutic procedures.

 (f)  A medical record shall include a provisional diagnoses; primary and secondary final diagnoses, the latter if necessary; a clinical resume; and, where appropriate, necropsy reports.

Authority

   The provisions of this §  115.32 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 §  115.32 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial page (37837).

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); 28 Pa. Code §  710.23 (relating to patient records); 28 Pa. Code §  711.43 (relating to client records); 28 Pa. Code §  711.53 (relating to client records); 28 Pa. Code §  711.62 (relating to client records); 28 Pa. Code §  711.72 (relating to client records); 28 Pa. Code §  711.83 (relating to client records); 28 Pa. Code §  711.93 (relating to client records); and 49 Pa. Code §  16.95 (relating to medical records).



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