Rule 3701-83-21. Medical records - ambulatory surgical facilities

119.03 Each medical record required by paragraph (A) of rule 3701-83-11 of the Administrative Code shall contain at least the following information as applicable for the surgery to be performed: (A) Admission data: (1) Name, address, date of birth, gender, and race or ethnicity; (2) Date and time of admission; and (3) Pre-operative diagnosis, which shall be recorded prior to or at the time of admission. (B) History and physical examination data: (1) Personal medical history, including but not limited to allergies, current medications and past adverse drug reactions; (2) Family medical history; and (3) Physical examination. (C) Treatment data: (1) Physician's, podiatrist's or dentist's orders; (2) Physician's, podiatrist's or dentist's notes; (3) Physician assistant's notes, if applicable; (4) Nurse's notes; (5) Medications; (6) Temperature, pulse, and respiration; (7) Any special examination or report, including but not limited to, x-ray, laboratory, or pathology reports; (8) Signed informed consent form; (9) Evidence of advanced directives and do-not-resuscitate orders, if applicable; (10) Operative record; (11) Anesthesia record, if applicable; and (12) Consultation record, if applicable. (D) Discharge data: (1) Final diagnosis; (2) Procedures and surgeries performed; (3) Condition upon discharge; (4) Post-treatment care and instructions; and (5) Attending physician's, podiatrist's or dentist's signature. (E) Other information required by law. Last updated August 1, 2023 at 2:26 PM Supplemental Information Authorized By: 3702.13 , 3702.30 Amplifies: 3702.12 , 3702.13 , 3702.30 7/15/2027 1/13/1996