Regulation .12 Medical Records.
Regulation .12 Medical Records.LinkCopy Citation
A.
The facility shall comply with COMAR 10.05.01.09 and the requirements of this regulation.
B.
Each medical record shall include, at a minimum:
(1)
Preoperative diagnostic studies, entered before surgery, if performed;
(2)
Findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those tissues exempted by the medical director;
(3)
Any allergies and abnormal drug reactions; and
(4)
Entries related to anesthesia administration.