Medical records - 28 Pa. Code § 117.43

A medical record shall be kept for every patient receiving emergency service, including:

• Patient identification data;
• Time of arrival;
• By whom transported;
• Pertinent history of injury or illness;
• Clinical, laboratory and roentgenologic findings;
• Diagnosis;
• Treatment given;
• Condition at time of discharge; and
• Final disposition, including instructions given for necessary follow-up.

Medical records of emergency services patients must be made part of any other patient medical record.  The emergency service medical records must be regularly reviewed to evaluate the quality of emergency medical care; special attention must be given to the records of patients dying within 24 hours of admission to the emergency service.