| (a) "Patient record" means any record regularly used,
created, or stored by a licensee or other person pertaining to a patient's
history, diagnosis, treatment, prognosis, or billing, including records
of other health care providers, currently or having been in the possession
or custody of the licensee or other person.
(b) "Initial visit" means a contact with a new patient,
a patient presenting a new condition or illness, or a patient presenting
a recurrence of a previous condition.
(c) A licensee shall ensure a patient record supports
all diagnoses, treatments, services, and billing.
(d) A licensee shall ensure a patient record is timely
created, accurately dated, legible, signed or initialed by the individual
who actually performed the treatment or service, and contains a key
to abbreviations.
(e) As a minimum, a licensee shall include the following
in all patient records created during an initial visit:
(1) patient history;
(2) description of symptoms or purpose of the visit;
(3) findings of examinations, including imaging and
laboratory records;
(4) assessment;
(5) diagnosis;
(6) prognosis;
(7) treatment plan, recommendations, and orders; and
(8) treatment or service provided and the patient's
response.
(f) Other than consultations, reports of findings,
or non-therapeutic contacts with a patient, a licensee shall include
in all records of a subsequent visit:
(1) an updated history since last visit, if any;
(2) the purpose of visit and changes in symptoms, if
any, since last visit;
(3) an examination of the area involved in the diagnosis;
(4) an assessment of any change in the patient's condition
since last visit;
(5) the treatment or service provided and the patient's
response; and
(6) change in treatment plan or planned referrals if
indicated.
(g) A licensee shall comply with all state and federal
documentation laws pertaining to health care providers.
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