<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".08" citation="COMAR 10.21.30.08" title_num="10" subtitle_num="21" chapter_num="30" heading="Medical Records.">
  <paragraph num="A.">
    <text>Originating Site. The originating site shall:</text>
    <paragraph num="(1)">
      <text>Be responsible for maintaining a complete medical record as if the individual were seen face-to-face at the originating site;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Meet the facility and community standard for medical record completion and retention, including applicable record reviews; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Be responsible for any proper release of information contained in an individual's medical record.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Distant Site.</text>
    <paragraph num="(1)">
      <text>The distant site shall maintain copies of all documentation completed by the distant site TMH provider unless the distant site TMH provider enters the information directly into the originating site's electronic medical record system.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The distant site, as part of its quality improvement system, shall have a process to review TMH care.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>As part of quality monitoring, when the originating site's electronic medical records are reviewed at the distant site, the:</text>
      <paragraph num="(a)">
        <text>Review may include the TMH provider's documentation online, if authorized; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Distant site may request sections of the individual's electronic medical record from the originating site for the distant site peer review.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>TMH records shall be retained according to the provisions of Health-General Article, §4-403, Annotated Code of Maryland.</text>
  </paragraph>
</regulation>