# COMAR Title 10 — Maryland Department of Health

## Subtitle 05 — Freestanding Ambulatory Care Facilities

### Chapter 01 — General Requirements

#### Regulation .09 Medical Records.

*COMAR 10.05.01.09*

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.