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Required Inpatient Patient Health Record Content – Cal. Code Regs. tit. 22 § 70749
Link to the law
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Current as of June 2015
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Each inpatient patient record must contain the following:
- Name
- Address at time of admission
- Identification number (Social Security, Medi-Cal, Medicare)
- Age
- Sex
- Marital status
- Religion
- Date of admission
- Date of discharge
- Emergency contact information
- Diagnosis
- History and physical exam
- Consultation reports
- Progress notes
- Nurses’ notes
- Vital signs
- Lab tests performed
- X-rays performed
- Consent forms
- Anesthesia reports
- Operative report, if performed
- Labor record, if performed
- Delivery record, if performed
- Discharge summary
Current as of June 2015
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