This chapter establishes the minimum standards for the documentation of patient care by the chiropractor. In this chapter, the following terms have the meanings indicated. Terms Defined. “Board” means the Maryland Board of Chiropractic Examiners. “Diagnosis” means the determination by the chiropractor of the nature and cause of a disease or injury through evaluation of patient history, examination, and review of any laboratory and radiological data. “Examination” means varied procedures such as analysis, assessment, and evaluation performed by the chiropractor to determine a diagnosis. "History" means the patient's account of past, present, and familial health. “Subjective, objective, assessment, and plan (SOAP) notes” means the written record maintained by the chiropractor of: The patient's qualitative or quantitative description of the patient's condition; Findings pertaining to the patient's condition based on examination and tests; The chiropractor's clinical opinion of the condition; and Instructions given to the patient, orthopedic appliances provided to the patient with instructions for usage, and recommendations for treatment, including modalities used and areas treated. The chiropractor shall maintain accurate, detailed, legible, and organized records, documenting all data collected pertaining to the patient's health status. The chiropractor may not erase, alter, or conceal patient records but shall initial and date any changes made in the corresponding margin. The Patient Record. The chiropractor shall create a record for each patient. The chiropractor shall state the patient's name or identification number on each document contained in the patient record. The chiropractor shall include the following information in the patient record: Chiropractor and clinic name identification; Patient history; Examination findings; Diagnoses; Treatment plan; SOAP notes; Financial records; Records of telephone conversations; Copies of correspondence and reports sent to other health care providers, diagnostic facilities, and legal representatives; Records and reports provided by other health care providers and diagnostic facilities; and The signed consent to treatment form of the: Patient; or Parent or guardian of a minor patient or incompetent patient. 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. Maintenance and Release of Patient Records. 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. The chiropractor shall release patient records when release is: Authorized by the patient in writing; or Compelled by law. 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. The chiropractor shall maintain records in accordance with Health-General Article, §4-403, Annotated Code of Maryland. The chiropractor is responsible for record keeping, consent to treatment forms, billing, and other patient-related documentation handled, maintained, or managed by the chiropractor’s staff. The chiropractor shall ensure that employees involved in the preparation, organization, and filing of records adhere to the regulations of this chapter. The chiropractor shall include the following in the patient history: Personal data, including: Name, Address, Telephone number, Date of birth, Race, Sex, and Current occupation; Complaint or complaints, including: Description of the complaint or complaints, Quality and character of the complaint or complaints, Intensity, Frequency, Location, Radiation, Onset, Duration, Palliative and provocative factors, and History of present complaint or complaints; Family health history; Past health history, including: General state of health, Previous illnesses, Surgical history, Previous injuries, Hospitalizations, Previous treatment and diagnostic testing, Prescribed and nonprescribed medications and supplements, Allergies, and Mental illness; Systems review, including: Musculoskeletal, Cardiovascular, Respiratory, Gastrointestinal, Neurological, Ophthalmological, Otolaryngological, Endocrine, Peripheral vascular, and Psychiatric; and Personal history, including: Occupational, Activities, Exercise, and Health habits. Violation of this chapter may result in disciplinary action against the chiropractor, as set forth in Health Occupations Article, §3-313, Annotated Code of Maryland. Health Occupations Article, §3-205, Annotated Code of Maryland Effective date: February 23, 1998 (25:4 Md. R. 244) Regulation .02B amended effective June 13, 2011 (38:12 Md. R. 705) Regulation .03B amended effective October 22, 2007 (34:21 Md. R. 1915) Chapter and Subtitle renamed and recodified from COMAR 10.43.15 to COMAR 10.43.14, Board of Chiropractic Examiners, Record Keeping, effective January 2, 2017 (43:26 Md. R. 1446) Regulation .03C amended effective December 30, 2019 (46:26 Md. R. 1165) Regulation .04A amended effective December 30, 2019 (46:26 Md. R. 1165)