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(c) A report of a finding on an x -ray examination made shall be <br />entered in the patient's record. <br />(d) Radiographic equipment shall be maintained in accord with <br />existing laws and rules. <br />503.17 TRANSPORTATION SERVICES. <br />A facility shall have available immediately adequate transportation <br />services for emergency patients requiring transfer to a hospital. A facility <br />shall be located not more than fifteen minutes normal travel time from <br />the hospital with which written emergency admission arrangements are <br />made. When indicated, a physician or nurse from the facility shall <br />accompany the patient to provide emergency care enroute. <br />503.18 MEDICAL RECORDS. <br />(a) Medical records shall be originated on all patients undergoing <br />surgery, signed by the responsible physician, indexed and so filed as to <br />assure their ready access and future availability. They shall be <br />maintained in accordance with a written retention policy acceptable to <br />the Director. In a hospital operated facility, the record keeping shall be <br />incorporated into the hospital medical records system, including and <br />subject to its established retention policies. <br />(b) Medical records shall contain as a minimum: <br />(1) Patient identification, including name, address, marital status <br />and birthdate. <br />(2) Medical history. <br />(3) Physical examination. <br />(4) Medical orders signed by the responsible physician. <br />(5) Laboratory findings. <br />(6) Special examination findings, for example, x -ray or <br />electrocardiogram. <br />(7) Preoperative and final diagnosis. <br />(8) Nurses' notes which shall include a recording of vital signs, pre - <br />and postoperatively, color, appearance and other relevant observations <br />with such frequency postoperatively as to document the patient's <br />stabilized condition at time of discharge. <br />(9) Record of the sedation and anesthetic used by product name and <br />dosage, identity of anesthetist if other than the surgeon, procedure and <br />any pertinent information concerning results or reactions. <br />(10) Written consultation reports signed by the consultant. <br />(11) Social or social service information relevant to the case. <br />(12) Surgeon's operative note including naming of procedure <br />performed, physician performing surgery, anesthetic agent used, names <br />of assistants (whether another physician, a nurse or specially trained <br />technician), duration of procedure and any unusual problems or <br />occurrences encountered, and surgeon's description of gross appearance <br />of tissues removed. <br />(13) Physician's progress notes and discharge note. The physician's <br />progress and discharge notes may be combined in the patient's clinical <br />record. <br />13 <br />