{"data":{"id":"us-dc/d.c.-code-44-533.06","jurisdiction":"us-dc","citation":"D.C. Code § 44-533.06","heading":"Center records and report requirements.","body":"(a)\nAccurate and complete clinical records shall be maintained for each patient and all entries in the clinical record shall be made at the time the surgical procedure is performed and when care, treatment, medications or other medical services are given. The record shall satisfy the diagnosis or need for medical services. It shall include where applicable but not be limited to the following:\n(1)\nPatient identification;\n(2)\nAdmitting information including patient history and physical examination;\n(3)\nSigned informed consent;\n(4)\nSigned and dated physician orders;\n(5)\nLaboratory tests, pathologist's report of tissue, and radiologist report of x-rays, as indicated by good medical practice;\n(6)\nAnesthesia record, if general anesthesia is used;\n(7)\nOperative record as indicated by good medical practice;\n(8)\nSurgical medication and medical treatments;\n(9)\nRecovery room notes;\n(10)\nPhysician and nurses' progress notes;\n(11)\nCondition at time of discharge; and\n(12)\nPatient instructions.\n\n(b)\nAccounting procedures shall be carried out in accordance with an accepted accounting system providing appropriate statistical information and shall permit satisfactory auditing.\n\n(c)\nEach facility shall submit reports on a regular basis containing such pertinent clinical and statistical data as may reasonably be required by the Department, including mortality and morbidity data.\n\n(d)\nAll patient records shall be confidential, unless the patient gives written consent for their release, except as provided in § 44-535.01.\n\n(e)\nAll hospitals licensed under the laws of the District of Columbia, including D.C. General Hospital, shall regularly report to the Department any incidence of morbidity in cases treated at a center.","path":["Title 44. Charitable and Curative Institutions.","Chapter 5. Health-Care and Community Residence Facility, Hospice and Home Care Licensure.","Subchapter I-A. Ambulatory Surgical Treatment Center Licensure.","Part C. Center Administration and Management."],"source_url":"https://code.dccouncil.gov/us/dc/council/code/sections/44-533.06","current_through":"2026-08-20 (D.C. Law 26-175)","vintage":"","retrieved_at":"2026-08-29T05:44:07Z","sha256":"ef087e35e42242fd8d1e823a31889338e3fc5dd57820e0aed940a996beb87230","source_id":"us-dc","stale":false,"prev":"us-dc/d.c.-code-44-533.05","next":"us-dc/d.c.-code-44-534.01"},"notice":"GroundRules: Original legal text. Not legal advice."}