Current through August 30, 2024
(a) A physician or
physician assistant licensed by the board shall maintain adequate records for
each patient for whom the licensee performs a professional service.
(b) Each patient record shall meet the
following minimum 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 that professional services were provided to the
patient;
(5) reflect what
examinations, vital signs, and tests were obtained, performed, or ordered
concerning the patient and the findings and results of each;
(6) indicate the chief complaint of the
patient;
(7) indicate the
licensee's diagnostic impressions of the patient;
(8) indicate the medications prescribed for,
dispensed to, or administered to the patient and the quantity and strength of
each medication;
(9) reflect the
treatment provided to or recommended for the patient;
(10) document the patient's progress during
the course of treatment provided by the licensee.
(c) Each entry in the patient record shall
reflect the identity of the individual making the entry.
(d) Each patient record shall include any
writing intended to be a final record. This subsection does not require the
maintenance of preliminary drafts, notes, other writings, or recordings once
this information is converted to final form and placed in the patient
record.
(e) The patient records for
a physician or physician assistant practicing under
AS
08.64.364 must comply with the requirements
of this section and include
(1) the physical
location of the patient and the physician or physician assistant when the
patient care was provided;
(2) a
description of the method of the communication between the physician or
physician assistant and patient;
(3) the name, location, and phone number,
state of Iicensure and license number of the physician, physician assistant or
other licensed health care provider available to provide follow-up care;
and
(4) if the prescribing
physician or physician assistant is not the patient's primary care provider,
documentation of the patient's consent to sending a copy of all records of the
encounter to the patient's primary care provider, and if the patient consents,
confirmation that the records were sent to the patient's primary care
provider.
Authority:AS
08.64.100
AS 08.64.107
AS
08.64.364
