Section 205.610  Clinical Records

Accurate and complete clinical records shall be maintained for each patient and all entries in the clinical record shall be made at the time the surgical procedure is performed and when care, treatment, medications, or other medical services are given.  The record shall include, but not be limited to, the following:

a)         patient identification.

b)         admitting information including patient history, physical examination findings, diagnosis or need for medical services.

c)         pre-counseling notes.

d)         signed informed consent.

e)         confirmation of pregnancy (when abortion is performed).

f)          signed physician orders.

g)         laboratory test reports, pathologist's report of tissue, and radiologist's report of x-rays.

h)         anesthesia record.

i)          operative record.

j)          medication and medical treatments.

k)         recovery room progress notes.

l)          physician and nurses' progress notes.

m)        condition at time of discharge.

n)         patient instructions.

o)         post-counseling notes.

(Source:  Amended at 3 Ill. Reg. 30, p. 371, effective July 23, 1979)