Content of Medical Record

(A) General Requirement. Medical records shall be retained for six years after the unit’s last treatment of a patient. The medical record shall be sufficiently detailed to enable effective continuing care to the patient, and to enable communication among the medical professionals contributing to the patient’s care. (B) Specific Provisions. Each medical record shall include at least the following: (1) Identification data including the patient's name, address, age and next of kin, and guardian, if any; (2) The name, address, and telephone number of the patient's designated practitioner; (3) History of present illness, past medical history, and family medical history; 145.540: continued (4) Records of initial and periodic physical examinations at intervals to be stated in written policies, approved by the medical director including all findings resulting from an assessment of all systems of the body; (5) Reports of all diagnostic procedures, tests, evaluations and examinations; (6) Records of treatment including order sheets, transfusion records, and record and date of each dialysis treatment; (7) Records of complications of treatment, accidents or untoward incidents regarding patients; (8) Progress notes, which shall be recorded in sufficient detail to delineate the course and results of treatment; (9) Information pertaining to hospital admissions during the patient's course of treatment, including a discharge summary from the hospital whenever possible; (10) A record of the patient's evaluations by an interdisciplinary team as set forth in 105 CMR 145.420. Records of annual evaluations shall list other methods of treatment considered and the indications for continued chronic maintenance dialysis, home dialysis, self-dialysis, transplantation or other methods of treatment; (11) Discharge summary or clinical resume, which shall briefly recapitulate the significant findings and events of the patient's dialysis treatments and arrangements made for future care; and (12) Date of admission and discharge.