<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".19" citation="COMAR 10.07.21.19" title_num="10" subtitle_num="07" chapter_num="21" heading="Medical Records.">
  <paragraph num="A.">
    <text>The hospice care program shall establish and maintain a clinical record for each patient in accordance with accepted principles of practice for maintaining medical records. The record is to be complete, accurately documented, readily accessible, and systematically organized to facilitate retrieval of information.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The hospice care program shall:</text>
    <paragraph num="(1)">
      <text>Document clinical and progress notes in a patient's medical record within 14 days of a visit or provision of services;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Obtain the attending physician's signature on an order within 30 days of receiving a verbal order; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Close a medical record within 30 days of a patient's discharge.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Access to or release of a patient's medical record by the hospice care program is permitted only with the consent of the patient or the patient's representative, or as required by law.</text>
  </paragraph>
  <paragraph num="D.">
    <text>If services are not provided directly by the hospice care program, the hospice care program shall obtain a copy of the applicable medical record or written summary of services provided and maintain it in the hospice care program's medical record.</text>
  </paragraph>
</regulation>