10A NCAC 14E .0305. MEDICAL RECORDS

(a)  A complete and permanent record shall be maintained for all patients including the date and time of admission and discharge; the full and true name; address; date of birth; nearest of kin; diagnoses; duration of pregnancy; condition on admission and discharge; referring and attending physician; a witnessed, voluntarily-signed consent for each surgery or procedure and signature of the physician performing the procedure; and the physician's authenticated history and physical examination including identification of pre-existing or current illnesses, drug sensitivities or other idiosyncrasies having a bearing on the operative procedure or anesthetic to be administered.

(b)  All other pertinent information such as pre- and post-operative instructions, laboratory report, drugs administered, report of operation and follow-up instruction including family planning advice shall be recorded and authenticated.

(c)  If Rh is negative, the significance shall be explained to the patient and so recorded.  The patient in writing may reject or accept the appropriate desensitization material.  A written record of the patient's decision shall be a permanent part of her medical record.

(d)  An ultrasound examination shall be performed and the results posted in the patient's medical record for any patient who is scheduled for an abortion procedure.

(e)  The facility shall maintain a daily procedure log of all patients receiving abortion services.  This log shall contain at least patient name, estimated length of gestation, type of procedure, name of physician, name of RN on duty, and date and time of procedure.

(f)  Medical records shall be the property of the facility and shall be preserved or retained in the State of North Carolina for at least 20 years regardless of change of facility ownership or administration.  Such medical records shall be made available to the Division upon request and shall not be removed from the premises where they are retained except by subpoena or court order.

(g)  The facility shall have a plan for destruction of medical records to identify information to be retained and the manner of destruction to ensure confidentiality of all material.

(h)  Should a facility cease operation, arrangements shall be made for preservation of records for at least 20 years.  The facility shall notify the Division, in writing, concerning the arrangements.

 

History Note:        Authority G.S. 14‑45.1(a);

Eff. February 1, 1976;

Readopted Eff. December 19, 1977;

Amended Eff. July 1, 1994; December 1, 1989.