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(10) consent forms;

(11) operative report on in-patient and out-patient surgery including pre-operative and post-operative diagnosis, description of findings, techniques used, and tissue removed or altered, if appropriate;

(12) anesthesia records including pre-operative diagnosis and post-anesthesia follow-up;

(13) a pathology report, if tissue or body fluid is removed;

(14) recovery room records;

(15) labor record;

(16) delivery record;

(17) record of a neonatal physical examination and condition on discharge;

(18) if the patient was in inpatient care for 48 hours or more, a discharge summary, prepared and signed by the attending physician or mid-level practitioner, that summarizes

(A) significant findings and events of the patient’s stay in the facility;

(B) conclusions as to the patient’s primary and any associated diagnoses; and

(C) disposition of the patient at discharge including instructions, medications, and recommendations and arrangements for future care; and

(19) if the patient was in inpatient care for less than 48 hours, a final discharge progress note signed by the attending physician or mid-level practitioner. (d) A facility must maintain procedures to protect the information in medical records from loss, defacement, tampering, or access by unauthorized persons. A patient’s written consent is required for release of information that is not authorized to be released without consent. A facility may not use or disclose protected health information except as required or permitted by 45 C.F.R. Part 160, subpart C, and 45 C.F.R. Part 164, subpart E, revised as of October 1, 2005, and adopted by reference. (e) A record must be completed within 30 days of discharge and authenticated or signed by the attending physician, dentist, or other practitioner responsible for treatment. The facility must establish policies and procedures to ensure timely completion of medical records. A record may be authenticated by a signature stamp or computer key instead of the treating practitioner’s signature if the practitioner has given a signed statement to the hospital administration that the practitioner is the only person who

(1) has possession of the stamp or key; and

(2) may use the stamp or key. (f) Medical records must be filed in accordance with a standard health information archival