10.05.05.12

.12 Medical Records.

A. The facility shall comply with COMAR 10.05.01.09 and the requirements of this regulation.

B. Each medical record shall include, at a minimum:

(1) Preoperative diagnostic studies, entered before surgery, if performed;

(2) Findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those tissues exempted by the medical director;

(3) Any allergies and abnormal drug reactions; and

(4) Entries related to anesthesia administration.