Each inpatient medical record shall
consist of at least the following:
Identification sheets to include but not be limited to the following:
(B) Address on admission.
Identification number (if applicable).
1. Hospital admission number.
2. Social Security number.
3. Medicare number.
4. Medi-Cal number.
(F) Marital status.
(G) Legal status.
(I) Date of admission.
(J) Date of discharge.
(K) Name, address and telephone number of
person or agency responsible for patient.
(L) Name of patient's medical staff member
responsible for care.
Discharge or final diagnosis.
Psychiatric history and physical examination.
(3) Legal authorization for
reports, including neurologic examination.
(5) Order sheet including medication,
treatment and diet orders.
(7) Progress notes
including current or working diagnosis, the complaints of others regarding the
patient, as well as the patient's comments.
Nurses' notes which shall include but not
be limited to the following:
(A) Concise and
accurate record of nursing care provided.
(B) Record of pertinent observation of the
patient and the response to treatment.
(C) Name, dosage and time of administration
of medications and treatment. Route of administration and site of injection
shall be recorded, if other than by oral administration.
(D) Record of type of restraint, including
time of application and removal.
(9) Vital sign sheet, including weight
(10) Reports of all
laboratory tests performed.
Reports of all X-ray examinations performed.
(12) Consent forms, when
(13) Anesthesia record
including preoperative diagnosis, if anesthesia has been
(14) Operative report
including preoperative and postoperative diagnosis, description of findings,
technique used, tissue removed or altered, if surgery was performed.
(15) Pathological report, if tissue or body
fluid was removed.
record, if applicable.
Delivery record, if applicable.
(18) A discharge summary which shall briefly
recapitulate the significant findings and events of the patient's
hospitalization, the patient's condition on discharge and the recommendation
and arrangements for future care.