Ohio Admin. Code 3701-83-23.3 - Medical records - freestanding dialysis centers
Each
(A) Patient information
including:
(1) Name, address, date of birth,
gender, and race or ethnicity;
(2)
History and physical examination data including allergies, current medications,
past adverse drug reactions, and family medical history;
(3) Diagnosis; and
(4) Dialysis prescriptions.
(B) Treatment data including;
(1) A written individualized comprehensive
patient care plan;
(2) Progress
notes; and
(3) Treatment notes
including dates and times the patient was on or off dialysis , pre-dialysis
safety checks, vital signs monitoring during dialysis , and notations of adverse
reactions.
(C)
Medication administration.
(D) Any
special examination or report, including x-ray, laboratory, or pathology
report.
(E) Signed consent for
treatment form.
(F) Documentation
indicating that the patient or patient 's representative received in writing the
following:
(1) Information on complaint
policies and grievance procedures;
(2) Information regarding the center 's policy
on advanced directives and do-not-resuscitate orders,
if applicable ; and
(3)
Information about the services to be performed.
(G) Documentation indicating that the patient
or patient 's representative received information about:
(1) Emergency self disconnect; and
(2) Measures to be taken in the event of an
at home post-treatment medical emergency.
(H) Discharge data including, condition upon
discharge, and post-discharge care and instructions.
(I) When a dialysis patient is transferred to
another
dialysis center
facility or to a facility for inpatient
care, the transferring dialysis facility
center
shall send all requested medical records
and information to the receiving
dialysis center
or facility within one day of the transfer.
Notes
Promulgated Under: 119.03
Statutory Authority: 3702.13; 3702.30
Rule Amplifies: 3702.12; 3702.13; 3702.30
Prior Effective Dates: 09/05/2002, 06/29/2009, 04/24/2011, 07/01/2016
Promulgated Under: 119.03
Statutory Authority: 3702.13, 3702.30
Rule Amplifies: 3702.12, 3702.13, 3702.30
Prior Effective Dates: 9/5/2002, 6/29/09, 4/24/11
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