(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.