Regulation .09 Medical Records.

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

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.

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.