(1) An individual clinical record must be established for each person receiving care. Each record must be accurate, legible, and promptly completed. The record must include at least the following:

(a) patient identification;

(b) significant medical history and results of physical examination;

(c) preoperative diagnostic studies, if performed;

(d) findings and techniques of the operation including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body;

(e) any allergies and abnormal drug reactions;

(f) entries related to anesthesia administration;

(g) documentation of properly executed informed patient consent which includes notice of transfer when deemed appropriate;

(h) discharge diagnosis; and

(i) discharge recommendations and instructions given to the patient.

(2) To ensure confidentiality, security, and physical safety of a patient's medical record, the outpatient center must designate a person to oversee and manage the clinical records.

(3) The outpatient center must have policies concerning clinical records. The policies must include:

(a) the retention of active records;

(b) the retirement of inactive records;

(c) the timely entry of data in records; and

(d) the release of information contained in records.

History: 50-5-103, MCA; IMP, 50-5-103, MCA; NEW, 2013 MAR p. 1626, Eff. 9/6/13.