12-5-14 VT. CODE R. §946 - Records under the Agency of Human Services regulations

A hospital must maintain medical records for every patient and retain the records for 10 years. Records must include the following:

·         Patient identification data

·         Complaint

·         Personal and family history

·         History of present illness

·         Physical & special examinations

·         Laboratory, x-ray and other examinations

·         Diagnoses

·         Medical or surgical treatment

·         Pathological findings

·         Progress notes

·         Discharge summary

·         Follow up

·         Autopsy findings

Medical records must be permanent, legible, and signed by the attending physician.