Documentation of Policies and Procedures. A burn center shall formally establish and maintain an organized burn service that is responsible for coordinating the care of the burn patient. A burn center shall maintain an organizational chart relating personnel within the burn unit to other hospital staff; a combined leadership model for trauma and burn center is acceptable. A burn center shall maintain an appropriate policy and procedure manual that: Is reviewed annually by the burn center director and the burn nursing leader; and Addresses: Administration of the burn center; Staffing and programs of the burn center; Criteria for admission to the burn unit by the burn service; Usage of the burn unit beds by other medical or surgical services; Criteria for discharge and follow-up care; Availability of beds and the transfer of burn patients to other medical or surgical units within the hospital; and Care of patients with burns in areas of the burn center other than the burn units. Consistency of Data Collected and Reported. The burn center shall participate in the State Burn Registry for burn patients, both inpatient and outpatient modules. The State Burn Registry shall include all patients who are treated at the burn center inclusive of outpatient and inpatient venues for burn care treatment. Minimum Volume for the Burn Center. A burn center shall treat an average of 100 or more unique inpatients and outpatients (ED treat and discharge and first clinic visit) with acute burn injuries annually. A burn center shall admit at least 60 patients annually who meet the referral criteria in Regulation .17 of this chapter.