Md. Code Regs. 10.12.03.06

Current through Register Vol. 51, No. 21, October 18, 2024

Section 10.12.03.06 - Medical Records

A. The facility shall maintain a complete, comprehensive, and accurate medical record for a patient.

B. A patient's medical record shall include at least the following:

(1) Patient identifier;

(2) Significant medical history and results of a physical examination;

(3) Documentation of care or services provided;

(4) Evidence of consent; and

(5) Discharge diagnosis.

C. The facility shall:

(1) Send a copy of the medical record with the patient on referral to another health care provider or on transfer to a hospital;

(2) Use the medical record, if appropriate, in instructing the patient and the family; and

(3) Comply with all disclosure requirements as set forth in Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland.

Md. Code Regs. 10.12.03.06

Regulation .06 adopted effective 41:24 Md. R. 1427, eff.7/1/2015