Section 11-4 - Patient Records (a) Basic Requirements. - (i) Each patient record shall, at a minimum, include legible documentation of the following:
- (A) The patient's identifying information and identity of the treating licensee and all health care providers;
- (B) The reason for the clinical encounter, including any subjective complaints and pertinent history;
- (C) The current objective findings and results of diagnostic studies;
- (D) The diagnosis and assessment of the patient's condition;
- (E) A management and care plan, including the recommendations, intended goals, prognosis, modifications to the plan, and the procedures provided;
- (F) Evidence that the patient was informed of any material risk relative to a proposed treatment/procedure and consented to receive this treatment/procedure.
- (G) Radiographs shall include the patient's first name, last name, date of birth, date of study, and location of study. It is preferable to embed this information in the radiograph.
(b) Records Retention. - (i) Licensees shall not withhold records or diagnostic studies if a patient owes an outstanding balance.
- (ii) Patient records and diagnostic studies shall be:
- (A) Maintained for a minimum of seven (7) years from the date of the last patient clinical encounter;
- (B) Maintained in a physically secure and confidential manner; and
- (C) Accessible to the patient and treating doctor within a reasonable period.
(c) Violation of any provision above shall be considered "unprofessional conduct" within the meaning of Chapter 7 and shall constitute grounds for disciplinary action by the Board.
030-11 Wyo. Code R. § 11-4