Medical records – Ohio Admin. Code 3701-83-23.3

Each patient medical record maintained by a health care facility (HCF) must include the following information:

• Patient information including:
  • Name, address, date of birth , gender, and race or ethnicity;
  • History and physical examination data including allergies, current medications, past adverse drug reactions, and family medical history;
  • Diagnosis; and
  • Dialysis prescriptions.
• Treatment data including;
  • A written individualized comprehensive patient care plan;
  • Progress notes; and
  • 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.
• Medication administration;
• Any special examination or report, including x-ray, laboratory, or pathology report; and
• Signed consent for treatment form.

When a dialysis patient is transferred to another facility or to a facility for inpatient care, the transferring facility must send all requested medical records and information to the receiving facility within one day of the transfer.