Requirements for Adequate Medical Records in Ambulatory Centers – 410 Ind. Admin. Code 15-2.5-3

An adequate medical record must be maintained for each patient of the center.  All medical records must be maintained by the center for seven years, be readily accessible, and be kept in a fire resistant structure.  Each record should be documented accurately and in a timely manner, be readily accessible, and permit prompt retrieval of information.  They must be retained in their original or legally reproduced form as required by federal or state law.  Plain paper faxes, reports, and documents are acceptable for inclusion in the medical record if allowed by the center policies.  Each medical record must contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and document accurately the course of the patient’s stay in the center and the results.  Additionally, each record should include:

• preoperative diagnostic studies if applicable
• any allergies and abnormal drug reactions
• evidence of any anesthesia administration
• appropriate informed consent forms for procedures and treatments
• discharge diagnoses
• medical history including chief complaint and physical examination
• a written report describing tissue removed or altered
• signatures of physicians and health care workers who treated or cared for the patient
• condition on discharge along with the disposition of the patient and time of dismissal
• final progress note that includes instructions to the patient and family
• a copy of the transfer form if the patient is referred to a hospital or other facility

All entries should be legible and complete, made only by authorized individuals and staff, and authenticated and dated.

Related Laws:

Ind. Code § 16-39-7-1