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SECTION 503.16 X-RAY ,qERVICES,
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<br />l. Ina facility ~fferlng ~,,rvlr-~,~ wl~l~l ,'~dinarily r~quiro dla?,nr~.qtlc x-ray
<br />examinations, appropriate arrangements .,:l~.~ll be made to assure their availability.
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<br />~.~ 2. Depending on the volume and urgency of x-ray needs, the facility shall' do one.
<br /> of the following:
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<br />a. Arrange with a nearby radiology service operated by a qualified,
<br /> radiologist for the provisiOn of the examination.
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<br />Provide appropriate x-ray equipment with necessary staff within the
<br />facility. In such f.~;t:~llntlon~:, the s,'rvlc, shall lm mnlnlaltmd m~der
<br />the dlrectIoil of n physician qual iilcd flor lh{, r~'*qmnsihllity nnd shall Include
<br />protection of patients and personnel from overexposure to radiation' or
<br />electric shock.
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<br />3. A report of a finding on an x-ray examination made shall be entered in the
<br />patient's record.
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<br />4.. Radiographic equipment .qhal, l be maintained in accord with existing law and rules.
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<br />SECTION 503.1~ TRANSI'ORTATION SERVICES.
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<br /> A facility stall have available immediately adeq,mte tran,~portation services for
<br /> emergency patients requiring transfer to a Immpitnl. A facility ~hnll be located
<br />*~, " not more than flftem~ (15) mim~ft':: nt~rm.ul lravel time from the hospital with which
<br /> written emergency admissim~ arr;m~nmt, nts are re:Mc Wl~en indi. caied, a physician or
<br /> "~' ~ld[se from the faciliky slutl.[ accm.tpany the patien~ to provide emergency care
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<br />SECTION 503.18 MEDICAl, RF, C(~RI)S.
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<br /> ]. Medical records shall bc oril,.in;~ied m~ all patients u'ndergoing surgery, signed
<br />by the responnible phy~:icl;~n, i.dcx~,d and st) filed a~ to ass.re their ready access
<br />· and future avaltahitity. 'l'l.'v si,all be m;~intained in accordance with a written
<br /> retention policy acccpt;~ble to thc director. I. n lu,nl~ltal opi, rated facility,
<br /> the record keeping ~fimll lm llU'O~p,~r;~I('d info Ih*' hm;l~it;~'l medical records system,
<br /> including and subject t:o its established retention policies.
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<br />2. Medical records shall contain as a mintmUm:
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<br />a. Patient identification, including name, address, marital status and btrthdate.
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<br />b. Medical history.
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<br />c. Physical exam.inet ion..
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<br />d. Medical orders signed by the .responsible physician.
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<br />e. Laboratory findings.
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<br />f. Special eXaminations,findings, for example, x-ray or electrocardiogram.
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<br /> g. Preoperative and final diagnosis.
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<br /> h. Nurses' note,q which shall im'lmle a recordings, of vital, signs, pre.~and post
<br />operatively, colbr, .appcar:~ncc, and otht, r rclevanf old,l-tv'aliens with such frequency
<br />postoperatively as to document the patient's stabilized condition at time of discharge.
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<br /> t. Record of tim se(Tat[on and ane?.thetlc u~:r,d hy prod,~ct name and donage, Jdentity
<br />· of anest'hetl.qt tf o~her lh:~. the surgeon, procedure ami any pertinent information
<br /> concerning results or rc;u:t.lons.
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<br />j. written .consultation reports signed by the consultant.
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<br />k. Social or social service Information relevant to tile case.
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<br /> l. Surgeon'.q opera! iw- note Including n;,ning of procedure performed, pl~ystcan
<br />performing surgery,
<br />phys.tctan, a m~rse or specially trnlnml tc,clmlcla.), d,~ratton of prec-dure and any
<br />unusual problems or oc-,~rrvnces encmmtert'd, and surgeon's description of gross
<br />appearance of tissues removed.
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