§ 115.33. Entries.
(a) All significant clinical information pertaining to a patient shall be incorporated in the patient’s medical record.
(b) Entries in the record shall be dated and authenticated by the person making the entry.
(c) Symbols and abbreviations may be used only when they have been approved by the medical staff and when there exists a legend to explain them.
(d) Oral orders shall include the date and signature of the person recording them. They shall be given and authenticated in accordance with the provisions of § 107.62 (relating to oral orders). All other orders shall be recorded in accordance with the provisions in § § 107.61 and 107.62—107.65 (relating to medical orders).
(e) A single signature on the face sheet of a record shall not suffice to authenticate the entire record. Each entry shall be individually authenticated.
(f) Notation of unusual incidents shall be entered in accordance with the provisions of § 109.37 (relating to unusual incidents) and Chapter 151 (relating to fire, safety and disaster services).
(g) Records of patients discharged shall be completed within 30 days following discharge.
Authority The provisions of this § 115.33 issued under 67 Pa.C.S. § § 6101—6104; and Reorganization Plan No. 2 of 1973 (71 P. S. § 755-2).
Source The provisions of this § 115.33 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial page (37838).
Cross References This section cited in 28 Pa. Code § 119.24 (relating to patient medical records); 28 Pa. Code § 135.13 (relating to patient’s medical record; preoperative procedures); and 49 Pa. Code § 16.95 (relating to medical records).
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