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Or. Admin. R. 847-017-0020 - Patient Medical Records

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A comprehensive medical record must be maintained for each patient who is evaluated or treated in an office-based surgery setting.  The record must include the following information:

  1. Identification information of the patient;
  2. Medical history and physical exam;
  3. Lab and diagnostic reports;
  4. Description of procedure being performed;
  5. Documentation and follow up;

Procedures must be established to maintain the confidentiality of the data.   


Current as of June 2015