10.05.01.09

.09 Medical Records.

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.