If a physician or surgeon conducts a scheduled medical procedure outside a general acute care hospital resulting in the patient's transfer to an emergency center, he must complete a form with specified information that is then placed in the patient's medical record.
Prescribing or dispensing dangerous drugs without a prior examination is not unprofessional conduct if the licensee transmitted the order to a nurse at an inpatient facility. Prior to transmitting the order the following conditions must be satisfied: the practitioner must consult with the nurse who reviewed the patient's records and the practitioner was designated to serve in the absence of the patient's practitioner.
A hospital having five or more physicians must adopt certain rules, including (1) periodic review of clinical experience based on medical records of patients; and (2) maintenance of adequate and accurate medical records.
Staff self-government, involving M.D. and D.O. physicians and surgeons, shall be accomplished by holding periodic meetings of the staff to review and analyze their clinical experience on the basis of patient medical records.
Occupational therapists are required to document evaluation, goals, treatment plan and summary of treatment in the patient record. These records shall be maintained for a minimum of seven years following patient's discharge, except records of a minor shall be maintained at least until one year after the minor.