Kan. Admin. Regs. § 100-24-1

Current through Register Vol. 40, No. 16, April 22, 2021
Section 100-24-1 - Adequacy; minimal requirements
(a) Each licensee of the board shall maintain an adequate record for each patient for whom the licensee performs a professional service.
(b) Each patient record shall meet these requirements:
(1) Be legible;
(2) contain only those terms and abbreviations that are or should be comprehensible to similar licensees;
(3) contain adequate identification of the patient;
(4) indicate the dates any professional service was provided;
(5) contain pertinent and significant information concerning the patient's condition;
(6) reflect what examinations, vital signs, and tests were obtained, performed, or ordered and the findings and results of each;
(7) indicate the initial diagnosis and the patient's initial reason for seeking the licensee's services;
(8) indicate the medications prescribed, dispensed, or administered and the quantity and strength of each;
(9) reflect the treatment performed or recom-mended;
(10) document the patient's progress during the course of treatment provided by the licensee; and
(11) include all patient records received from other health care providers, if those records formed the basis for a treatment decision by the licensee.
(c) Each entry shall be authenticated by the person making the entry unless the entire patient record is maintained in the licensee's own handwriting.
(d) Each patient record shall include any writing intended to be a final record, but shall not require the maintenance of rough drafts, notes, other writings, or recordings once this information is converted to final form. The final form shall accurately reflect the care and services rendered to the patient.
(e) For purposes of implementing the healing arts act and this regulation, an electronic patient record shall be deemed a written patient record if the electronic record cannot be altered and if each entry in the electronic record is authenticated by the licensee.

Kan. Admin. Regs. § 100-24-1

Authorized by K.S.A. 65-2865; implementing K.S.A. 1997 Supp. 65-2837, as amended by L. 1998, ch. 142, §19 and L. 1998, ch. 170, §2; effective, T-87-42, Dec. 19, 1986; effective May 1, 1987; amended June 20, 1994; amended Nov. 13, 1998.