Current through Register Vol. 56, No. 18, September 16, 2024
(a) Licensees
shall maintain written, contemporaneous patient records, which include:
1. Findings upon initial examination
including the patient's significant past history and results of appropriate
tests and measures;
2. A written
plan of care indicating the goals of the treatment program, the type of
treatment, and the frequency and expected duration of treatment for audiology
and/or speech-language pathology services;
3. Dated documentation of each treatment
rendered, which contains the licensee's full name and license number;
4. Dated and signed progress notes;
5. Documentation of any changes in the
treatment program;
6. Documentation
of any contact with other health professionals relative to the patient's
care;
7. A discharge summary which
includes the reason for discharge and the outcome of services rendered;
and
8. Any pertinent legal document
such as patient release forms or charge access sheets.
(b) Treatment records for patients shall be
maintained for at least seven years from date of the most recent entry. Records
for minors shall be kept for seven years from the date of the most recent entry
or until the patient turns 20 years old, whichever is longer.
(c) Licensees shall provide access to patient
treatment records to a patient or person whom the patient has designated to
receive records in accordance with the following:
1. No later than 30 days from receipt of a
request from a patient or a person whom the patient has designated to receive
records, the licensee shall provide a copy of the professional treatment record
and/or billing records as may be requested. The record shall include all
pertinent objective data including test results, as applicable, and subjective
information;
2. The licensee may
require that a record request be in writing and may charge a fee for the
reproduction of records, which shall be no greater than $ 1.00 per page or $
100.00 for the entire record, whichever is less. If the record requested is
less than 10 pages, the licensee may charge up to $ 10.00 to cover postage and
the costs associated with retrieval of the record;
3. If the patient or a subsequent treating
health care professional is unable to read the patient record, either because
it is illegible or prepared in a language other than English, the licensee
shall, upon request, provide an English transcription at no cost to the
patient; and
4. The licensee shall
not refuse to provide a patient record on the grounds that the patient owes the
licensee an unpaid balance.
(d) All licensees shall prepare, within 30
days of a written request from a patient or any person whom the patient has
designated to receive such, a written report summarizing the information set
forth in (a) above.
