mandatory record keeping

Results for mandatory record keeping

Summary:

The medical director of each state hospital for the mentally disordered must make a roster of the gravely disabled persons within the institution. Officer in charge of investigating conservatorships within a county shall be provided with the names and pertinent records of patients to be provided conservatorship investigation.

Associated Federal Law(s): 
164.512(b)
Summary:

The psychiatrist conducting the independent medical review of an inpatient minor must keep a record of the proceeding. After considering all of the clinical information, the psychiatrist shall issue a binding decision whether to continue in-patient treatment.

Associated Federal Law(s): 
164.506(a)
Summary:

The physician or surgeon last in attendance with a patient must complete and attest to the medical and health section data and the time of death for the purposes of registering a death. If the patient is in a skilled nursing or intermediate care facility, a licensed physician assistant may complete and attest to such provided that the assistant is legally authorized to do so and has visited the patient within 72 hours before death. When coroners are required to fill out such data, then they must certify and attest to the facts.

Associated Federal Law(s): 
Summary:

The physician or surgeon last in attendance, or a licensed physician's assistant if patient was in a intermediate care facility at time of death, must state on the death certificate the disease or condition directly leading to death, antecedent causes, other significant conditions contributing to death, and any other medical and health section data required.

Associated Federal Law(s): 
Summary:

The second section of the death certificate shall include the disease or condition leading directly to death and antecedent causes, operations and major findings thereof, accident and injury information, and information regarding whether decedent was pregnant at the time of death or a year prior to death.

Associated Federal Law(s): 
Summary:

Within 15 hours of delivery the physician in attendance during the delivery of a fetus, shall state on the fetal death certificate: the time of fetal death or delivery, the direct causes of fetal death and any conditions giving rise to the causes, and other required medical health and section data. The physician shall sign the certificate to attest to the facts.

Associated Federal Law(s): 
Summary:

When information originally provided in the medical and health data section of any record of death, fetal death, or live birth is modified, the certifying physician or coroner may make a declaration stating the changes needed to make the information correct and file it with the state or local registrar.

Associated Federal Law(s): 
Summary:

Nonprofit speech and hearing center shall: provide periodic progress reports to the physician and surgeon or other professional referring the patient; maintain a complete record of all services rendered with respect to each patient.

Associated Federal Law(s): 
164.506(a)
Summary:

If the patient (or the patient's spouse or legal guardian) refuses to consent to the patient's transfer, the noncontracting hospital shall provide written notice indicating that the patient will be financially responsible for any further poststabilization care provided by the hospital. The hospital shall give one copy of the written notice to the patient (or the patient's spouse or legal guardian) for signature and may retain a copy in the patient's medical record.

Associated Federal Law(s): 
Summary:

When an individual is pronounced dead on account of having sustained an irreversible cessation of all functions of the brain including the brain stem, complete patient medical records required of a health facility pursuant to Health & Safety Code 1275 shall be kept, maintained, and preserved.

Associated Federal Law(s): 
164.512(g)
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