# COMAR Title 10 — Maryland Department of Health

## Subtitle 05 — Freestanding Ambulatory Care Facilities

### Chapter 05 — Freestanding Ambulatory Surgical Facilities

#### Regulation .12 Medical Records.

*COMAR 10.05.05.12*

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.