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

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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.

Current as of June 2015