SECTION 310:667-19-13. Promptness of record completion

(a)   Current records and those on discharged patients shall be completed promptly.

(b)   All dictated reports shall include the date of dictation and the date of transcription.

(c)   Medical record transcription shall be timely. Current records; e.g. progress notes, consultation reports, operative notes, radiology reports, shall be transcribed and available for review in the medical record within forty-eight (48) hours of dictation.

(d)   History and physical examinations shall be completed, signed, and placed in the medical record within forty-eight (48) hours following admission or not more than thirty (30) days prior to admission.

(e)   When the medical history and physical examination are completed within thirty (30) days before admission, the hospital must ensure that an updated medical record entry documenting an examination for any changes in the patient's condition is completed. A timely review of the prior history and physical examination or an updated examination must be completed and documented in the patient's medical record within forty-eight (48) hours.

(f)   Records of patients discharged shall be completed within thirty (30) days following discharge.

(g)   If a patient is readmitted within thirty (30) days for the same condition, reference to the previous history and physical examination with an interval note shall suffice.

[Source: Added at 12 Ok Reg 1555, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok Reg 1664, eff 6-12-03; Amended at 24 Ok Reg 1189, eff 4-2-07 (emergency); Amended at 25 Ok Reg 2472, eff 7-11-08]