Plain Text Law

Regulation .12 Medical Records.

Regulation .12 Medical Records.Copy 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.