Medical record documentation requirements

§ 2899-j. Medical record documentation requirements. An attending physician shall document or file the following in the patient's medical record: 1. the dates of all oral requests by the patient for medication under this article; 2. the written request by the patient for medication under this article, including the declaration of witnesses and interpreter's declaration, if applicable; 3. the attending physician's diagnosis and prognosis, determination of decision-making capacity, and determination that the patient is acting voluntarily, of the patient's own volition and without coercion, and has made an informed decision; 4. written determination of decision-making capacity under section twenty-eight hundred ninety-nine-i of this article; and 5. a note by the attending physician indicating that all requirements under this article have been met and indicating the steps taken to carry out the request, including a notation of the medication prescribed or ordered.