Code of the District of Columbia

§ 44–533.06. Center records and report requirements.

(a) 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 satisfy the diagnosis or need for medical services. It shall include where applicable but not be limited to the following:

(1) Patient identification;

(2) Admitting information including patient history and physical examination;

(3) Signed informed consent;

(4) Signed and dated physician orders;

(5) Laboratory tests, pathologist's report of tissue, and radiologist report of x-rays, as indicated by good medical practice;

(6) Anesthesia record, if general anesthesia is used;

(7) Operative record as indicated by good medical practice;

(8) Surgical medication and medical treatments;

(9) Recovery room notes;

(10) Physician and nurses' progress notes;

(11) Condition at time of discharge; and

(12) Patient instructions.

(b) Accounting procedures shall be carried out in accordance with an accepted accounting system providing appropriate statistical information and shall permit satisfactory auditing.

(c) Each facility shall submit reports on a regular basis containing such pertinent clinical and statistical data as may reasonably be required by the Department, including mortality and morbidity data.

(d) All patient records shall be confidential, unless the patient gives written consent for their release, except as provided in § 44-535.01.

(e) All hospitals licensed under the laws of the District of Columbia, including D.C. General Hospital, shall regularly report to the Department any incidence of morbidity in cases treated at a center.