Section 410IAC26-7-2. Content of the medical record

   (a) The medical record for surgical abortions must be accurate and contain sufficient information to do the following:

(1) Identify the patient to include name, age, and address.

(2) Document the following:

(A) Tests, examinations, and procedures performed.

(B) The course of the patient's stay in the clinic and the results.

  (b) Entries in the medical record must be as follows:

(1) Legible.

(2) Complete.

(3) Made by authorized individuals as specified in clinic and medical staff policies.

(4) Authenticated and dated in accordance with this article.

  (c) Patient records for surgical abortions must document and contain, at a minimum, the following:

(1) Patient identification.

(2) Appropriate medical history.

(3) Results of the following:

(A) A physical examination.

(B) Diagnostic or laboratory studies, or both (if performed).

(4) Any allergies and abnormal drug reactions.

(5) Entries related to anesthesia administration.

(6) Evidence of appropriate informed consent for procedures and treatments as required by IC 16-34-2-1.1.

(7) A report describing techniques, findings, and tissue removed or altered.

(8) Authentication of entries by the physician or physicians and health care workers who treated or cared for the patient.

(9) Condition on discharge, disposition of the patient, and time of discharge.

(10) Discharge entry to include instructions to the patient or patient's legal representative.

(11) A copy of the following:

(A) The transfer form if the patient was referred to a hospital or other facility.

(B) The terminated pregnancy report filed with the department.

(12) Any report filed with a state agency or law enforcement agency pursuant to a statutory reporting requirement.

  (d) An appropriate history and physical examination report must be in the patient's chart before a surgical abortion. The report shall include, but is not limited to, the following:

(1) Vital signs.

(2) Allergies.

(3) Any significant risk factors.

(4) The date written.

(Indiana State Department of Health; 410 IAC 26-7-2; filed May 11, 2006, 9:36 a.m.: 29 IR 3363; readopted filed Jul 12, 2012, 12:08 p.m.: 20120808-IR-410120196RFA)