<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".03" citation="COMAR 10.43.14.03" title_num="10" subtitle_num="43" chapter_num="14" heading="Record Keeping.">
  <paragraph num="A.">
    <text>The chiropractor shall maintain accurate, detailed, legible, and organized records, documenting all data collected pertaining to the patient's health status.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The chiropractor may not erase, alter, or conceal patient records but shall initial and date any changes made in the corresponding margin.</text>
  </paragraph>
  <paragraph num="C.">
    <text>The Patient Record.</text>
    <paragraph num="(1)">
      <text>The chiropractor shall create a record for each patient.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The chiropractor shall state the patient's name or identification number on each document contained in the patient record.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The chiropractor shall include the following information in the patient record:</text>
      <paragraph num="(a)">
        <text>Chiropractor and clinic name identification;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Patient history;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Examination findings;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Diagnoses;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Treatment plan;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>SOAP notes;</text>
      </paragraph>
      <paragraph num="(g)">
        <text>Financial records;</text>
      </paragraph>
      <paragraph num="(h)">
        <text>Records of telephone conversations;</text>
      </paragraph>
      <paragraph num="(i)">
        <text>Copies of correspondence and reports sent to other health care providers, diagnostic facilities, and legal representatives;</text>
      </paragraph>
      <paragraph num="(j)">
        <text>Records and reports provided by other health care providers and diagnostic facilities; and</text>
      </paragraph>
      <paragraph num="(k)">
        <text>The signed consent to treatment form of the:</text>
        <paragraph num="(i)">
          <text>Patient; or</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Parent or guardian of a minor patient or incompetent patient.</text>
        </paragraph>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Correspondence. The chiropractor shall identify the name of the attending chiropractor, clinic name, address, and telephone number on patient records and reports sent to another health care provider.</text>
  </paragraph>
  <paragraph num="E.">
    <text>Maintenance and Release of Patient Records.</text>
    <paragraph num="(1)">
      <text>The chiropractor shall keep confidential all information contained in the patient file, in accordance with Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The chiropractor shall release patient records when release is:</text>
      <paragraph num="(a)">
        <text>Authorized by the patient in writing; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Compelled by law.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>The chiropractor may assess fees for duplicating patient records for the patient or for another health care provider in accordance with Health-General Article, §4-304, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(4)">
      <text>The chiropractor shall maintain records in accordance with Health-General Article, §4-403, Annotated Code of Maryland.</text>
    </paragraph>
  </paragraph>
</regulation>