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37.106.1001    MINIMUM STANDARDS FOR AN OUTPATIENT FACILITY

(1) Nursing services must be provided by or under the supervision of a licensed registered nurse.

(2) Standing orders utilized for emergency or post-operative care shall be recorded in each patient's medical record and dated and signed by his licensed physician.

(3) An outpatient facility shall maintain a medical record for each patient which includes, but is not limited to, the following information:

(a) identification data;

(b) chief complaint;

(c) present illness;

(d) medical history;

(e) physical examination;

(f) laboratory and x-ray reports;

(g) treatment administered;

(h) tissue report;

(i) progress reports;

(j) discharge summary.

History: Sec. 50-5-103 and 50-5-404, MCA; IMP, Sec. 50-5-103, 50-5-204 and 50-5-404, MCA; NEW, 1980 MAR p. 1587, Eff. 6/13/80; TRANS, from DHES, 2002 MAR p. 185.

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