MN ADC 4640.1000

Medical Records

All hospitals must maintain accurate and complete medical records on each patient from admission to discharge.  To be considered complete, the record must include:

A.  identification information;

B.  admitting diagnosis;

C.  history and physical exam;

D. progress notes;

E.  signed doctor’s orders;

F.  operative notes;

G. special notes and examinations, such as x-rays or lab findings;

H.  nurse’s notes;

I.  discharge notes;

J.  autopsy report, if applicable

A medical record should be maintained on all newborns and should include a physician statement of condition at discharge.  The hospital should note the name and address of an individual taking the child if it is someone other than the child’s parents.  There must be a policy in place to have medical records completed within a reasonable time after discharge, which is the responsibility of the attending physician.