Section 24. Patient Records

Each facility licensed pursuant to these regulations must maintain a medical record for each patient. Every record must be accurate, legible and promptly completed. Medical records must include at least the following: A. Ambulatory surgical centers: (1) patient identification; (2) significant medical history and results of physical examination; (3) pre-operative diagnostic studies (entered before surgery), if performed; (4) findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body; (5) any allergies and abnormal drug reactions; (6) entries related to anesthesia administration; (7) documentation of properly executed informed patient consent; and (8) discharge diagnosis; 8.370.18 NMAC 8 B. Diagnostic and treatment centers, rural health clinics, limited diagnostic and treatment centers: (1) patient identification; (2) patient consent forms (if applicable); (3) pertinent medical history; (4) assessment of the health status and health care needs of the patient; (5) brief summary of the episode for which the patient is requiring care; (6) disposition, and instructions to the patient; (7) reports of physical examinations, diagnostic and laboratory test results, and consultative findings; and (8) all physician's orders, reports of treatments and medication and other pertinent information necessary to monitor the patient's progress; C. Infirmaries: (1) same as Paragraphs (1) through (8) of Subsection B of 8.370.18.24 NMAC above; (2) nursing notes (for those patients requiring overnight care or observation); and (3) medication chart (if applicable); D. New or innovative outpatient service: (1) same as Paragraphs (1) through (8) of Subsection B of 8.370.18.24 NMAC] above; (2) any other information deemed necessary by the licensing authority after review and approval of the new or innovative service.