Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 3
Subtitle 22 - DEVELOPMENTAL DISABILITIES
Chapter 10.22.02 - Administrative Requirements for Licensees
Section 10.22.02.13 - Records

Universal Citation: MD Code Reg 10.22.02.13

Current through Register Vol. 51, No. 19, September 20, 2024

A. A licensee shall maintain records for each individual at the site where the individual is being served.

B. The records shall include at a minimum:

(1) The identifying information which appears on the individual's application for services from the Administration;

(2) Sufficient information that enables the licensee to provide services in a manner which ensures the individual's health and safety, including:
(a) An emergency contact person for the individual,

(b) The names of the individual's next of kin,

(c) The individual's physician,

(d) The individual's current diagnosis,

(e) Documented allergies of the individual, and

(f) A listing of the medications the individual receives;

(3) The IP as defined in COMAR 10.22.05;

(4) Documentation demonstrating implementation of the IP; and

(5) Any other information the Administration may require.

C. On notification of a medical emergency, the licensee shall ensure that the individual's medical information is available and readily accessible to emergency personnel.

D. The licensee shall:

(1) Maintain an individual's records for a minimum of 6 years, regardless of whether the individual is no longer being served or dies;

(2) Maintain documents relevant to the services the individual is currently receiving, as long as the individual is being served; and

(3) Organize an individual's record in a manner that facilitates easy access to needed information.

E. Electronic Records.

(1) The licensee is encouraged to use electronic records whenever possible.

(2) Electronic records shall:
(a) Meet requirements in this chapter;

(b) Comply with the HIPAA privacy and security rules pertaining to personal health information (PHI); and

(c) Be properly backed up and stored at an off-site location.

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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