Sec.19a-14-40. Medical records, definition, purpose

The purpose of a medical record is to provide a vehicle for: documenting actions taken in patient management; documenting patient progress; providing meaningful medical information to other practitioners should the patient transfer to a new provider or should the provider be unavailable for some reason. A medical record shall include, but not be limited to, information sufficient to justify any diagnosis and treatment rendered, dates of treatment, actions taken by non-licensed persons when ordered or authorized by the provider; doctors' orders, nurses notes and charts, birth certificate worksheets, and any other diagnostic data or documents specified in the rules and regulations. All entries must be signed by the person responsible for them.

(Effective August 29, 1984)