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(D) patient’s date of birth;
(E) patient’s sex;
(F) patient’s marital status;
(G) patient’s religious preference;
(H) date of admission;
(I) name, address, and telephone number of a contact person;
(J) name of the patient’s attending physician;
(K) initial diagnostic impression;
(L) date of discharge and final diagnosis; and
(M) source of payment;
(2) a medical and psychiatric history and examination record;
(3) consultation reports, dental records, and reports of special studies;
(4) an order sheet which includes medication, treatment, and diet orders signed by a physician;
(5) progress notes for each service or treatment received;
(6) nurses’ notes which must include
(A) an accurate record of care given;
(B) a record of pertinent observations and response to treatment including psychosocial and physical manifestations;
(C) an assessment at the time of admission;
(D) a discharge plan;
(E) the name, dosage, and time of administration of a medication or treatment, the route of administration and site of injection, if other than by oral administration, of a medication, the patient’s response, and the signature of the person who administered the medication or treatment; and
(F) a record of any restraint used, showing the duration of usage;
(7) court orders relevant to involuntary treatment;
(8) laboratory reports;
(9) x-ray reports;