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· ' m. Phy,~lclan's prol',r~'~;~ ~w~l.t,~ ;~l (ti Is.'~r~? at)lo. 'l'h~' physician's progress and <br />discharge notes may be combined In the p.., i..nt's clinical record. <br /> <br /> 11. Sum~l;Iry of i.r:tr~,cti~.~; ~',lvt'll for I,,1 l(~w~ll~ obr-;t,rV;ltJon ;lll(l C,ql-O a~ well n~ <br />.recording't~[ all referr:~lr~ for cotmselin~, family plaything or other medical conditions <br />requiring further attention. <br /> <br /> o. !dentification of the physician who actually discharges the patient. <br /> <br />3. Medical records .~h:,I.1 1.7o :~v;iil:d~le for survey a,~d review of content at any time <br />by authorized members of the department. <br /> <br />~. Medical records shall be maintained as confidential documents with the following <br />exceptions: <br /> <br />Information required under these rules. <br /> <br />Information required by law. <br /> <br />Information authorized for disclos, re by written release by the patient. <br /> <br />5. A {ac[lt.t'y lt~ wl)lcl~ nl,o~.t io.~: mt-(' lw,~l.)~,,~,d ~:l~:~ll t:w~lntai~) record.~ o[ tho <br />procedures, and .~ha] 1. file r('pnrls a.d fur.lsh si:at l,~tical and .~t~ch other information <br />as may be req. lred by ,:he director. The dl. roct.r ,<lw~tl t:~ke adeq,~ate measures to <br />protect the confidentiality Of identity.of th~ patient from the. public. <br /> <br />There shall be reported on f~rm~q provided I)y the director which shall include at a <br />minimum the .followin~ tnform;~tion: .~ <br /> <br /> Ct <br /> <br /> f. <br /> <br /> g. <br /> <br /> h. <br /> <br /> i. <br /> <br />k. <br /> <br />1, <br /> <br /> mo <br /> <br />.n. <br /> <br /> Oo <br /> <br />p, <br /> <br />q. <br /> <br />t. <br /> <br />U. <br /> <br /> Name and address of the facility· <br /> <br /> Patient, ~umlw, r (ibc, Jdt~t I ty .f t l,~, patient to be kept separate from the <br /> patient number on public records.) <br /> <br /> Date of abortion. <br /> <br /> Zip code of residence of pregnant female. <br /> <br /> Age of pregnant ferns.lc, nml impreg~w~ting male, if known. <br /> <br /> Race. <br /> <br /> Marital status of pregnant femaIe, ami impregnating male, if known. <br /> <br /> Number of previous pregnancies. <br /> <br /> Years of education. <br /> <br /> Number of living children. <br /> <br /> Number of previous induced abortion, spontaneous ~bortions and still-births. <br /> Dmte of last induced abortion. <br /> <br /> Date of last live birth and health of said'child at birth. <br /> <br /> Date of beginning of last n~nstrnal period. <br /> <br />Stated reason for abortion. <br /> <br />Medical condlt <br /> <br />Blood type <br /> <br />Type of abortion procedure. <br /> <br />Medical indication for abortl, on, tf any. <br /> <br />Complications noted tf any from prev'lo~ or present termination procedures. <br />All certifications rcquircd by this Chapter. <br /> <br /> <br />