Medical records – Ohio Admin. Code 3701-83-21

Each ambulatory surgical facility must maintain a record for each patient that contains the following information as applicable to the surgery to be performed:

• Name, address, date of birth, gender, and race or ethnicity of the patient;
• Date and time of admission;
• Pre-operative diagnosis, recorded prior to or at the time of admission;
• Personal medical history, including allergies, current medications and past adverse drug reactions;
• Family medical history;
• Physical examination;
• Treatment data, including signed informed consent form and evidence of advanced directives, if applicable;
• Final diagnosis;
• Procedures and surgeries performed;
• Condition upon discharge; and
• Post-treatment care and instructions.