A. The facility shall maintain a complete, comprehensive, and accurate medical record for each patient.
B. Each patient's medical record shall include at least the following:
(1) Patient identifier;
(2) Significant medical history and results of a physical examination;
(3) Documentation of care or services provided;
(4) Evidence of consent; and
(5) Discharge diagnosis.
C. The facility shall:
(1) Send a copy of the medical record with the patient on referral to another health care provider or on transfer to a hospital;
(2) Use the medical record, if appropriate, in instructing the patient and the family; and
(3) Comply with all disclosure requirements as set forth in Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland.