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Medical records – Ohio Admin. Code 3701-83-23.3

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Each patient medical record maintained by a health care facility

 (HCF) must include the following information:

  • Patient information including:
    • Name, address, date of birth , gender, and race or ethnicity;
    • History and physical examination data including allergies, current medications, past adverse drug reactions, and family medical history;
    • Diagnosis; and
    • Dialysis prescriptions.
  • Treatment data including;
    • A written individualized comprehensive patient care plan;
    • Progress notes; and
    • Treatment notes including dates and times the patient was on or off dialysis, pre-dialysis safety checks, vital signs monitoring during dialysis, and notations of adverse reactions.
  • Medication administration;
  • Any special examination or report, including x-ray, laboratory, or pathology report; and
  • Signed consent for treatment form.

When a dialysis patient is transferred to another facility or to a facility for inpatient care, the transferring facility must send all requested medical records and information to the receiving facility within one day of the transfer.

Current as of June 2015