N.Y. Comp. Codes R. & Regs. Tit. 10 § 755.7 - Medical record system

In addition to the requirements of section 751.7 of this Title, the medical record shall contain the following information:

(a) a history, physical examination, pertinent preoperative diagnostic studies and a preoperative diagnosis incorporated into the medical record prior to surgery;

(b) a record of any allergies and abnormal drug reactions;

(c) evidence of the appropriate written informed consent for surgery;

(d) preoperative and post-operative instructions;

(e) anesthesia record;

(f) an operative report describing surgical procedures performed and findings, completed by the individual performing the operation;

(g) post-operative follow-up report, including any post-operative abnormalities or complications;

(h) pathology reports on anatomical parts and tissues removed during surgery;

(i) a discharge diagnosis; and

(j) follow-up plans.

Notes

N.Y. Comp. Codes R. & Regs. Tit. 10 § 755.7