18 Va. Admin. Code § 90-70-230

Current through Register Vol. 41, No. 10, December 30, 2024

Section 18VAC90-70-230 - Medical records

The prescriber shall keep current, accurate, and complete records in an accessible manner and readily available for review to include:

1. The medical history and physical examination;

2. Past medical history;

3. Applicable records from prior treatment providers or any documentation of attempts to obtain those records;

4. Diagnostic, therapeutic, and laboratory results;

5. Evaluations and consultations;

6. Treatment goals;

7. Discussion of risks and benefits;

8. Informed consent and agreement for treatment;

9. Treatments;

10. Medications, including date, type, dosage and quantity prescribed, and refills;

11. Patient instructions; and

12. Periodic reviews.

18 Va. Admin. Code § 90-70-230

Derived from Virginia Register Volume 40, Issue 10, eff. 1/31/2024.

Statutory Authority: §§ 54.1-2400 and 54.1-2957.04 of the Code of Virginia.