7 AAC 13.115 - Patient records
(a) A facility shall maintain an organized
records system that contains the following for each patient:
(1) a description of history, physical
findings, and laboratory results for each visit;
(2) an assessment and, where appropriate, a
diagnosis;
(3) a treatment plan;
and
(4) a record of medications
prescribed.
(b) Facility
staff shall complete a patient record at the time of the visit. The person
recording a visit shall sign and date the entry.
Notes
Authority:AS 18.25.100
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