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105. Mass. Code Regs. 145.540. - Content of Medical Record
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Current as of June 2015
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“Content of Medical Record”
This section establishes the requirements for medical records keeping. Each medical record shall be sufficiently detailed to enable a physician to give effective continuing care to the patient, as well as to enable a physician to determine, at a future date, what the patient's condition was at a specific time and what procedures were performed. It should also be detailed enough that a consulting physician or another physician can assume the care of the patient at any time. It should include identification data, medical history, records of physical examinations, reports of all diagnostic procedures, records of treatment, records of complications of treatment, and progress notes. It shall also have information pertaining hospital admissions and discharge summary from the hospital.
Current as of June 2015
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