Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 3
Subtitle 12 - ADULT HEALTH
Chapter 10.12.01 - Surgical Abortion Facilities
Section 10.12.01.13 - Medical Records
Universal Citation: MD Code Reg 10.12.01.13
Current through Register Vol. 51, No. 19, September 20, 2024
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. With the patient's consent or to the extent that information in a record is necessary for a patient's care in an emergency transfer, the facility shall:
(1)
Send a copy of the medical record with the patient on:
(a) Referral to another physician or other
licensed health professional; or
(b) Transfer to a hospital;
(2) If appropriate, and with the
patient's consent, use the medical record when 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.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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