§ 117.43. Medical records.
(a) A medical record shall be kept for every patient receiving emergency service, and it shall become an official hospital record.
(b) The medical record shall include:
(1) Patient identification data.
(2) Time of arrival.
(3) By whom transported.
(4) Pertinent history of injury or illness.
(5) Clinical, laboratory and roentgenologic findings.
(6) Diagnosis.
(7) Treatment given.
(8) Condition at time of discharge.
(9) Final disposition, including instructions given for necessary follow-up.
(c) Every record shall be signed by the physician in attendance who is responsible for its clinical accuracy.
(d) A review of emergency service medical records shall be conducted regularly to evaluate the quality of emergency medical care. Special attention shall be given to the records of patients dying within 24 hours of admission to the emergency service.
(e) Nonphysicians may write in patient medical records in accordance with § 107.12 (relating to content of bylaws, rules and regulations).
(f) Medical records of emergency services patients shall be made part of any other patient medical record maintained in accordance with § 115.31 (relating to patient medical records).
Authority The provisions of this § 117.43 issued under 67 Pa.C.S. § § 6101—6104 (Repealed); and Reorganization Plan No. 2 of 1973 (71 P. S. § 755-2) (Renumbered).
Source The provisions of this § 117.43 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial page (37849).
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