10.43.14.03

.03 Record Keeping.

A. The chiropractor shall maintain accurate, detailed, legible, and organized records, documenting all data collected pertaining to the patient's health status.

B. The chiropractor may not erase, alter, or conceal patient records but shall initial and date any changes made in the corresponding margin.

C. The Patient Record.

(1) The chiropractor shall create a record for each patient.

(2) The chiropractor shall state the patient's name or identification number on each document contained in the patient record.

(3) The chiropractor shall include the following information in the patient record:

(a) Chiropractor and clinic name identification;

(b) Patient history;

(c) Examination findings;

(d) Diagnoses;

(e) Treatment plan;

(f) SOAP notes;

(g) Financial records;

(h) Records of telephone conversations;

(i) Copies of correspondence and reports sent to other health care providers, diagnostic facilities, and legal representatives;

(j) Records and reports provided by other health care providers and diagnostic facilities; and

(k) The signed consent of the patient or the parent or guardian of a minor patient or incompetent patient.

D. Correspondence. The chiropractor shall identify the name of the attending chiropractor, clinic name, address, and telephone number on patient records and reports sent to another health care provider.

E. Maintenance and Release of Patient Records.

(1) The chiropractor shall keep confidential all information contained in the patient file, in accordance with Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland.

(2) The chiropractor shall release patient records when release is:

(a) Authorized by the patient in writing; or

(b) Compelled by law.

(3) The chiropractor may assess fees for duplicating patient records for the patient or for another health care provider in accordance with Health-General Article, §4-304, Annotated Code of Maryland.

(4) The chiropractor shall maintain records in accordance with Health-General Article, §4-403, Annotated Code of Maryland.