§ 135.13. Patient’s medical record; preoperative procedures.
(a) The record of surgery shall be maintained in accordance with § § 115.31—115.33 (relating to patient medical records; contents; and entries).
(b) After the patient has been placed on the operating table, it is the responsibility of the primary operating surgeon and the person administering anesthesia to properly identify the patient and to document this identification in the patient’s medical record. This procedure shall be set forth in written policies designating the mechanism to be used to identify each surgical patient.
(c) Procedures shall be established to ensure that, except in emergencies, at least the following data are recorded in the medical record of the patient prior to surgery:
(1) Verification of identity of patient.
(2) Medical history and supplemental information regarding drug sensitivities and other pertinent facts.
(3) General physical examination, details of significant abnormalities, and evaluation of the capacity of the patient to withstand anesthesia and surgery.
(4) Provisional diagnosis.
(5) Laboratory test results.
(6) Consultation reports.
(7) Signed informed consent obtained by the surgeon.
(8) X-ray reports.
(9) Dental X-ray reports if applicable.
Authority The provisions of this § 135.13 amended under section 2102(g) of The Administrative Code of 1929 (71 P. S. § 532(g)); and section 803 of the Health Care Facilties Act (35 P. S. § 448.803).
Source The provisions of this § 135.13 adopted December 9, 1977, effective December 10, 1977, 7 Pa.B. 3631; amended December 3, 1982, effective December 4, 1982, 12 Pa.B. 4129. Immediately preceding text appears at serial pages (52862) to (52863).
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