LAC 48:I.9389
LAC 48:I.9389. Content
Cite as La. Admin. Code tit. 48, pt. I, § 9389
A. The medical record shall contain the following minimum data:
1. unique patient identification data;
2. admission and discharge dates;
3. complete history and physical examination, in accordance with medical staff policies and procedures;
4. provisional admitting diagnosis and final diagnosis;
5. medical staff orders;
6. progress notes;
7. nursing documentation and care plans;
8. record of all medical care or treatments;
9. discharge summary; and
10. documents, records, photos, testimonials, and other significant health-related collateral information provided by a patient’s family member, caregiver, friend, or licensed healthcare practitioner when deemed relevant to the patient’s care or treatment by the licensed healthcare practitioner.
B. The medical record shall contain the following when applicable:
1. clinical laboratory, pathological, nuclear medicine, radiological and/or diagnostic reports;
2. consultation reports;
3. pre-anesthesia note, anesthesia record, and post-anesthesia notes;
4. operative reports;
5. obstetrical records, including:
a. record of mother's labor, delivery, and postpartum period;
b. separate infant record containing date and time of birth, condition at birth, sex, weight at birth if condition permits weighing, and condition of infant at time of discharge;
c. autopsy reports; and/or
d. any other reports pertinent to the patient's care.