<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".13" citation="COMAR 10.12.01.13" title_num="10" subtitle_num="12" chapter_num="01" heading="Medical Records.">
  <paragraph num="A.">
    <text>The facility shall maintain a complete, comprehensive, and accurate medical record for a patient.</text>
  </paragraph>
  <paragraph num="B.">
    <text>A patient's medical record shall include at least the following:</text>
    <paragraph num="(1)">
      <text>Patient identifier;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Significant medical history and results of a physical examination;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Documentation of care or services provided;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Evidence of consent; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Discharge diagnosis.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>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:</text>
    <paragraph num="(1)">
      <text>Send a copy of the medical record with the patient on:</text>
      <paragraph num="(a)">
        <text>Referral to another physician or other licensed health professional; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Transfer to a hospital;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>If appropriate, and with the patient's consent, use the medical record when instructing the patient and the family; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Comply with all disclosure requirements as set forth in Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland.</text>
    </paragraph>
  </paragraph>
</regulation>