Md. Code Regs. 10.07.21.19

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.07.21.19 - Medical Records

A. The hospice care program shall establish and maintain a clinical record for each patient in accordance with accepted principles of practice for maintaining medical records. The record is to be complete, accurately documented, readily accessible, and systematically organized to facilitate retrieval of information.

B. The hospice care program shall:

(1) Document clinical and progress notes in a patient's medical record within 14 days of a visit or provision of services;

(2) Obtain the attending physician's signature on an order within 30 days of receiving a verbal order; and

(3) Close a medical record within 30 days of a patient's discharge.

C. Access to or release of a patient's medical record by the hospice care program is permitted only with the consent of the patient or the patient's representative, or as required by law.

D. If services are not provided directly by the hospice care program, the hospice care program shall obtain a copy of the applicable medical record or written summary of services provided and maintain it in the hospice care program's medical record.

Md. Code Regs. 10.07.21.19

Regulations .19 adopted effective August 10, 1998 (25:16 Md. R. 1274)