<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".05" citation="COMAR 10.21.02.05" title_num="10" subtitle_num="21" chapter_num="02" heading="Records.">
  <paragraph num="A.">
    <text>Clinical records shall contain sufficient information to identify the patient clearly, to support the diagnosis, to justify the treatment plan, and to document the results accurately.</text>
  </paragraph>
  <paragraph num="B.">
    <text>A clinical record shall be established for every person admitted to a day treatment program and shall include:</text>
    <paragraph num="(1)">
      <text>Identifying information, including names, current addresses, and telephone numbers of the patients, relatives, or guardians;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Presenting problem, the results of mental and physical examinations, diagnosis, treatment plan, a record of the implementation of the treatment plan, and the discharge disposition and referrals;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Evidence of appropriate release-of-information procedures and informed consent, if applicable.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>A system of identification and filing of clinical records shall be maintained to facilitate the prompt location of the patient's clinical record.</text>
  </paragraph>
  <paragraph num="D.">
    <text>Provision shall be made for storing records to assure their security and to maintain their confidentiality.</text>
  </paragraph>
  <paragraph num="E.">
    <text>The record shall be retained for at least 3 years after the discharge of a patient unless the patient is a minor. In that case, it shall be retained for at least 3 years past the date on which the minor would reach the age of majority. Record retention by State or State-funded programs shall conform to the requirements of the records management division.</text>
  </paragraph>
</regulation>