D.C. Mun. Regs. tit. 17, r. 17-4709

Current through Register 71, No. 45, November 7, 2024

Rule 17-4709 - PREPARATION OF PATIENT RECORDS; ELECTRONIC RECORDS; ACCESS TO OR RELEASE OF INFORMATION; CONFIDENTIALITY; TRANSFER OR DISPOSAL OF RECORDS

4709.1

The following words and terms, as used in this section, shall have the following meanings unless the context clearly indicates otherwise:

(a) "Authorized representative" means a person who has been designated by the patient or a court to exercise rights under this section. An authorized representative may be the patient's attorney or an employee of an insurance carrier with whom the patient has a contract which provides that the carrier be given access to records to assess a claim for monetary benefits or reimbursement. If the patient is a minor, a parent or guardian who has custody (whether sole or joint) shall be deemed to be an authorized representative.

(b) "Patient" means any person who is the recipient of acupuncture.

4709.2

Acupuncturists shall prepare contemporaneous, permanent professional treatment records. Acupuncturists shall also maintain records relating to billings made to patients and third party carriers for professional services. All treatment records, bills, and claim forms shall accurately reflect the treatment or services rendered. Treatment records shall be maintained for a period of three years from the date of the most recent entry.

(a) To the extent applicable, professional treatment records shall reflect:

(1) The dates of all treatments;

(2) The patient complaint;

(3) The history;

(4) Progress notes;

(5) Any orders for tests or consultations and the results thereof;

(6) Documentation indicating that informed consent was given by the patient;

(7) Findings from examinations;

(8) If a physician or other licensed health care practitioner has referred a patient for acupuncture, an indication that a referral or diagnosis was made, including the name of the referring professional; and

(9) Documentation of any recommendations made to a patient for the use of practices or products that facilitate health.

(b) Corrections or additions may be made to an existing record, provided that each change is clearly identified as such, dated and initialed by the licensee;

(c) A patient record that is prepared and maintained electronically shall be prepared and maintained as follows:

(1) The patient record shall contain at least two forms of identification, for example, name and record number or any other specific identifying information;

(2) The entry made by the acupuncturist shall be made contemporaneously with the treatment and shall contain the date of service, date of entry, and full printed name of the treatment provider. The acupuncturist shall finalize or "sign" the entry by means of a confidential personal code ("CPC") and include date of the "signing";

(3) The acupuncturist may dictate a dated entry for later transcription. The transcription shall be dated and identified as "preliminary" until reviewed, finalized and dated by the acupuncturist as provided in § 4709.2(c)(2);

(4) The electronic record system shall contain an internal permanently activated date and time recordation for all entries, and shall automatically prepare a back-up copy of the file;

(5) The electronic record system shall be designed in such manner that after "signing" by means of the CPC, the existing entry cannot be changed in any manner. Notwithstanding the permanent status of a prior entry, a new entry may be made at any time and may indicate correction to a prior entry;

(6) Where more than one acupuncturist is authorized to make entries into the electronic record of a patient, the acupuncturist responsible for the acupuncture practice shall assure that each such person obtains a CPC and uses the file program in the same manner; and

(7) A copy of each day's entry, identified as preliminary or final as applicable, shall be made available to a physician responsible for the patient's care or to a representative of the Board, no later than ten (10) days after a request for the record, or to a patient within thirty (30) days of the request or promptly in the event of emergency.

4709.3

Acupuncturists shall provide access to professional treatment records to a patient or the patient's authorized representative in accordance with the following:

(a) No later than thirty (30) days from receipt of a request from a patient or an authorized representative, the acupuncturist shall provide a copy of the professional treatment record, and/or billing records as may be requested. The record shall include all pertinent objective data including test results as applicable, as well as any subjective information.

(b) Unless otherwise required by law, an acupuncturist may, if a patient requests, provide a summary of the record in lieu of providing a photocopy of the actual record, so long as that summary adequately reflects the patient's history and treatment. An acupuncturist may charge a reasonable fee for the preparation of a summary, which has been provided in lieu of the actual record, which shall not exceed the cost allowed by § 4709.3(c) for that specific record.

(c) Acupuncturists may require that a record request be in writing and may charge a reasonable fee for the reproduction of records.

(d) If the patient or a subsequent treating health care professional is unable to read the treatment record, either because it is illegible or prepared in a language other than English, the acupuncturist shall provide a transcription at no cost to the patient.

(e) The acupuncturist shall not refuse to provide a professional treatment record on the grounds that the patient owes the licensee an unpaid balance if the record is needed by another health care professional for the purpose of rendering care.

4709.4

Acupuncturists shall maintain the confidentiality of professional treatment records,except that:

(a) The acupuncturist shall release patient records as directed by a subpoena issued by the Board. Such records shall be originals, unless otherwise specified, and shall be unedited, with full patient names. To the extent that the record is illegible, the acupuncturist, upon request, shall provide a typed transcription of the record. If the record is in a language other than English, the acupuncturist shall also provide a certified translation.

(b) The acupuncturist shall release information as required by law or regulation.

(c) The acupuncturist, in the exercise of professional judgment and in the best interests of the patient (even absent the patient's request), may release pertinent information about the patient's treatment to another licensed health care professional who is providing or has been asked to provide treatment to the patient, or whose expertise may assist the acupuncturist in his or her rendition of professional services.

4709.5

Where the patient has requested the release of a professional treatment record or a portion thereof to a specified individual or entity, in order to protect the confidentiality of the records, the acupuncturist shall:

(a) Secure and maintain a current written authorization, bearing the signature of the patient or an authorized representative;

(b) Assure that the scope of the release is consistent with the request; and

(c) Forward the records to the attention of the specific individual identified or mark the material "Confidential."

4709.6

If an acupuncturist ceases to engage in practice or it is anticipated that he or she will remain out of practice for more than three (3) months, the acupuncturist or designee shall:

(a) Establish a procedure by which patients can obtain a copy of the treatment records or acquiesce in the transfer of those records to another licensee who is assuming responsibilities of the practice. However, an acupuncturist shall not charge a patient, pursuant to § 4709.3(c), for a copy of the records, when the records will be used for purposes of continuing treatment or care.

(b) Make reasonable efforts to directly notify any patient treated during the six months preceding the cessation, providing information concerning the established procedure for retrieval of records.

D.C. Mun. Regs. tit. 17, r. 17-4709

Final Rulemaking published at 36 DCR 7159, 7163 (October 13, 1989); amended by Final Rulemaking published at 66 DCR 7413 (6/21/2019)