Section 146.115  Records and Data Reporting Requirements

a)         In addition to any other Department record requirements, the ambulatory surgical treatment center (ASTC) must maintain complete, comprehensive and accurate medical records to ensure adequate patient care that includes, but is not limited to, the following:

1)         Patient identification.

2)         Significant medical history and results of physical examination.

3)         Preoperative diagnostic studies (entered before surgery), if performed.

4)         Findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body of the ASTC or State law.

5)         Any known allergies and abnormal drug reactions.

6)         Entries related to anesthesia administration.

7)         Documentation of properly executed informed patient consent.

8)         Discharge diagnosis.

9)         Medications ordered and administered.

b)         ASTC medical records must contain the dates of service and the name of the medical practitioner seeing the patient at the time of each center visit.

c)         Medical records for Medical Assistance patients must be made available to the Department or its designated representative in the performance of utilization review.

d)         The ASTC agrees to furnish to the Department, if requested, information necessary to establish payment rates in the form and manner that the Department requires.

e)         Services provided in an ASTC may be subject to prepayment and post-payment review to assess medical care, coding validation and quality of care.

(Source:  Amended at 38 Ill. Reg. 15152, effective July 2, 2014)