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Medical Records - 10-144-125 Me. Code R. § 4.I

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Ambulatory Surgical Facilities must keep complete, comprehensive and accurate medical records to ensure proper patient care.  Each patient must have his or her own record, which includes patient identification, significant medical history and results of physical examinations, any allergies and drug reactions, discharge diagnoses, documentation of informed patient consent, documentation of anesthesia administration, and operative and pre-operative studies.


Current as of June 2015