Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter X
Sec2 144-101-X-4 - Limited Family Planning Benefit
Subsection 144-101-X-4.07 - ENROLLEE'S RECORDS

A. The Enrollee's name, address, and birth date;

B. The Enrollee's medical and social history, including immunization records, as appropriate;

C. A description of the findings from the physical examination;

D. Long and short range medical goals, as appropriate;

E. A description of any tests ordered and performed and their results;

F. A description of treatment, counseling, or follow-up care provided and the dates scheduled for revisits;

G. Notation of any medications and/or supplies dispensed or prescribed;

H. Recommendations for and referral to other sources of care;

I. The dates on which all services were provided; and

J. Written progress notes, which shall identify the services provided.

Other qualified staff (woman's specialists, educators, etc.) may sign record entries relative to history-taking, updates, instruction, and pregnancy testing and results.

Entries are required for each date of service billed and must include the name, title, and signature of the service provider.