44:76:10:03Surgical

records. When surgery is performed, the following record requirements apply: (1) An operating room register shall be maintained and shall include the patient's name, identification number or medical record number, date of operation, inclusive or total time of the operation or procedure, name of surgeon and all assistants, nursing personnel, type of anesthesia and name of person administering, operation or procedure performed, preoperative and postoperative diagnosis, and age of patient; (2) The patient's medical record, including at least a medical history, a copy of the physician's examination, copies of laboratory tests, radiology reports, a signed consent for the surgical procedure to be performed, and a preoperative diagnosis, shall be made available in the surgical suite at the time of surgery; and (3) An accurate and complete description of the operative procedure that includes a preoperative and postoperative diagnosis shall be recorded by the operating surgeon within 48 hours following completion of surgery.

Source: 42 SDR 51, effective October 13, 2015.