Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 19 - Medical Records Department › Section 310:667-19-8 - Content

Current through Vol. 41, No. 20, July 1, 2024
(a) The medical record shall contain
				sufficient information to justify the diagnosis and warrant the treatment
				provided. The medical record shall contain the following information:
(1) Identification data. Identification data
				shall include at least the patient's name, address, age and date of birth, sex,
				and marital status.
(2) Date of
				admission.
(3) Date of
				discharge.
(4) Chief complaint. The
				chief complaint shall consist of a concise statement describing the reason the
				patient is seeking medical attention.
(5) History of present illness. The history
				of the present illness shall include a detailed description of the patient's
				symptoms including:
(A) Location of
				pain;
(B) Quality of pain and
				symptoms;
(C) Severity;
(D) Timing;
(E) Duration;
(F) Modifying factors, i.e., things that
				worsen or alleviate symptoms; and
(G) Associated signs and symptoms.
(6) Past history. The past history
				shall include all previous illnesses and previous surgical
				procedures.
(7) Medication history.
				The medication history shall list all current medications and all know drug
				reactions/allergies.
(8) Social
				history. The social history shall include a description of the patient's social
				setting and use of tobacco and/or alcohol, illicit drugs, and work
				history.
(9) Family history. The
				family history shall include a description of the state of health of living
				first-degree relatives, and causes of death of first-degree
				relatives.
(10) Review of systems.
				Elements of the review of systems shall include:
(A) General overall condition (fever, weight
				loss, stamina, etc.);
(B) Head,
				eyes, ears, nose, throat;
(C)
				Cardiovascular;
(D)
				Respiratory;
(E) Breasts;
(F) Gastrointestinal;
(G) Genitourinary;
(H) Musculoskeletal;
(I) Skin and lymphatics;
(J) Neurological;
(K) Psychiatric;
(L) Hematologic;
(M) Allergic; and
(N) Immunologic.
(11) Physical examination. The physical
				examination shall include a record of the patient's vital signs at the time of
				the examination including height, weight, blood pressure, temperature, pulse
				rate, and respiratory rate. Negative findings for a system may be indicated in
				the record of the physical examination by the lack of an entry for that system.
				If the hospital allows negative findings for a system on physical examination
				to be documented by omission of an entry for that system, medical records
				policies and procedures shall specify whether the omission of an entry
				signifies the system was examined and no significant findings were noted or
				that no examination of that system was performed. Specific abnormal or
				pertinent negative findings of the examination of the affected or symptomatic
				body area(s) must be documented in regards to the following areas:
(A) Head, eyes, ears, nose, and
				throat;
(B) Neck;
(C) Chest, including lungs, breasts, and
				axilla;
(D) Cardiovascular,
				including peripheral pulses, and examination of abdominal aorta;
(E) Abdomen;
(F) Genitourinary;
(G) Hematologic and Immunologic;
(H) Musculoskeletal;
(I) Neurological;
(J) Psychiatric; and
(K) Skin and lymphatics.
(12) Provisional diagnosis which shall be an
				impression (diagnosis) reflecting the examining physician's or licensed
				independent practitioner's evaluation of the patient's condition and shall be
				based mainly upon physical findings and history.
(13) Special examinations, if any, such as
				clinical laboratory reports, diagnostic imaging studies, consultation reports,
				etc. Consultation reports shall be a written opinion and shall be signed by the
				consultant, including his or her findings from the history and physical
				examination of the patient.
(14)
				Treatment and medication orders.
(15) Diagnostic and medical procedure
				reports.
(16) Surgical records
				including anesthesia record, preoperative diagnosis, operative procedure and
				findings, postoperative diagnosis, and tissue diagnosis on all specimens
				examined. Tissue reports shall include a report of microscopic findings if
				hospital regulations require that microscopic examination be done. If only
				gross examination is warranted, a statement that the tissue has been received
				and a gross description shall be made by the laboratory and filed in the
				medical record.
(17) Progress and
				nursing notes shall give a chronological picture of the patient's progress and
				shall be sufficient to delineate the course and results of treatment. The
				condition of the patient shall determine the frequency with which they are
				made.
(18) Record of temperature,
				pulse, respiration, and blood pressure.
(19) Definitive final diagnosis expressed in
				terminology of a recognized system of disease nomenclature.
(20) Discharge Summary that shall be a
				recapitulation of the significant findings and events of the patient's
				hospitalization and condition upon discharge, including prescribed medications
				at time of discharge.
(21) Autopsy
				findings in a complete protocol shall be filed in the record when an autopsy is
				performed.