37.106.512 MEDICAL, CLINICAL, AND HEALTH RECORD INFORMATION
(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.