Sec.19-13-D49. Records

Latest version.

(a) There shall be adequate provisions for the retention and storage of medical or dental records with adequate space and equipment and qualified medical record personnel, if necessary.
(b) A medical or dental record shall be started for each patient at the time of admission, including proper identifying data. Medical and dental records shall include sufficient information to justify the diagnosis made and warrant the treatment given or services provided. Each entry shall be signed by the person responsible for it.
(c) Medical and dental records shall be filed in the clinic in a manner accessible to the professional staff, with proper provision for their confidentiality, and shall be kept for a minimum of five years after discharge of the patient.

(Effective April 4, 1972)

                    
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