Regulation .13 Medical Records.
Regulation .13 Medical Records.LinkCopy Citation
A.
The facility shall maintain a complete, comprehensive, and accurate medical record for a patient.
B.
A 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.
With the patient's consent or to the extent that information in a record is necessary for a patient's care in an emergency transfer, the facility shall:
(1)
Send a copy of the medical record with the patient on:
(a)
Referral to another physician or other licensed health professional; or
(b)
Transfer to a hospital;
(2)
If appropriate, and with the patient's consent, use the medical record when 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.