NAC449.61384. Contents of medical records.

The medical record of each patient of an independent center for emergency medical care must be complete, authenticated, accurate and current. Each medical record must contain the following:

     1. A complete identification of the patient, including information on his or her next of kin and the person or agency who is legally or financially responsible for the patient;

     2. A statement concerning the admission and diagnosis of the patient;

     3. The medical history of the patient;

     4. Evidence of any informed consent given by the patient or his or her legal guardian for the care of the patient;

     5. Any clinical observation of the patient, including notes of a physician, nurse or any other professional in attendance;

     6. Reports of all prescribed tests and examinations of the patient;

     7. Confirmation of the original diagnosis or, if the diagnosis changed, the diagnosis at the time of discharge;

     8. A summary of the discharge of the patient prepared in accordance with established policy, including any provisions made for the continuing care or follow-up treatment of the patient after his or her discharge; and

     9. If the patient has died, the documentation of death and necropsy report, if available.

     (Added to NAC by Bd. of Health, eff. 11-1-95)