10.12.01.13

.13 Medical Records.

A. The facility shall maintain a complete, comprehensive, and accurate medical record for a patient.

B. A 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. With the patient's consent or to the extent that information in a record is necessary for a patient's care in an emergency transfer, the facility shall:

(1) Send a copy of the medical record with the patient on:

(a) Referral to another physician or other licensed health professional; or

(b) Transfer to a hospital;

(2) If appropriate, and with the patient's consent, use the medical record when 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.