Current through Register Vol. 56, No. 18, September 16, 2024
(a) A contemporaneous, permanent patient
record shall be prepared and maintained by a licensee, which may include
information collected by licensed chiropractic assistants, for each person
seeking chiropractic services, regardless of whether any care is actually
rendered or whether any fee is charged. Licensees also shall maintain records
relating to billings made to patients and third party carriers for professional
services. All patient records, bills, and claim forms shall accurately reflect
the care or services rendered. Such records shall include, as a minimum:
1. The name, address, and date of birth of
the patient and, if a minor, the name of the parent or guardian;
2. The patient complaint/reason for
visit;
3. A pertinent case
history;
4. Findings on appropriate
examination;
5.
Diagnosis/analysis;
6. A care
plan;
7. Any orders for tests or
consultations including the clinical indications and the results
thereof;
8. The dates of each
patient visit;
9. A description of
care or services rendered at each visit together with the name of the licensee
or other person rendering the care;
10. Notation of significant changes in
patient's condition and/or significant changes in care plan;
11. Periodic notation of patient status
regardless of whether significant changes have occurred; and
12. An itemized statement of the amount
billed and received on patient's account.
(b) Patient records, including all
radiographs and other diagnostic findings, shall be maintained for at least
seven years from the date of the last entry. In the case of a minor child,
records shall be kept for seven years from the date of the last entry or seven
years from the date of majority, whichever is later.
(c) All radiographs shall be labeled, as a
minimum, with the following identifying information:
1. The name of patient;
2. The date of radiograph;
3. The age of patient and/or date of
birth;
4. The name of facility;
and
5. Right or left
identity.
(d) Licensees
shall provide access to patient records to the patient or the patient's
authorized representative in accordance with the following:
1. Upon receipt of a written request from a
patient or an authorized representative and within 30 days thereof, legible
copies of the patient record including, if requested, copies of radiographs,
shall be furnished to the patient or an authorized representative or another
designated health care provider. To the extent that the record is illegible or
prepared in a language other than English, the licensee shall provide a typed
transcription and/or translation at no cost to the patient.
2. Except where the complete record is
required by applicable law, the licensee may elect to provide a summary of the
record, as long as that summary accurately reflects the patient's history and
care, where the written request comes from an insurance carrier or its agent
with whom the patient has a contract which provides that the carrier be given
access to records to assess a claim for monetary benefits or
reimbursement.
3. A licensee shall
provide copies of records in a timely manner to a patient or another designated
health care provider where the patient's continued care is contingent upon
their receipt. The licensee shall not refuse to provide a patient record on the
grounds that the patient owes the licensee an unpaid balance if the record is
needed by another health care professional for the purpose of rendering
care.
4. A licensee may refuse to
release a record to a patient if, in the exercise of professional judgment, a
licensee has reason to believe that the patient may be harmed by release of the
subjective information contained in the patient record or a summary thereof.
The record or the summary, with an accompanying notice setting forth the
reasons for the original refusal, shall nevertheless be provided upon request
of and directly to:
i. The patient's
attorney;
ii. Another licensed
health care professional; or
iii.
The patient's health insurance carrier.
5. The licensee may charge a reasonable fee
for the reproduction of records, which shall be no greater than an amount
reasonably calculated to recoup the cost of copying or transcription.
(e) Licensees shall maintain the
confidentiality of patient records, except that:
1. Upon receipt of a written request from a
patient or an authorized representative and within 30 days thereof, legible
copies of the patient record including, if requested, copies of radiographs,
shall be furnished to the patient or an authorized representative or another
designated health care provider. To the extent that the record is illegible or
prepared in a language other than English, the licensee shall provide a typed
transcription and/or translation at no cost to the patient.
2. The licensee, in the exercise of
professional judgment and in the best interests of the patient (even absent the
patient's request), may release pertinent information about the patient's care
to another licensed health care professional who is providing or who has been
asked to provide care to the patient, or whose expertise may assist the
licensee in his or her rendition of professional services.
3. A licensee shall provide copies of records
in a timely manner to a patient or another designated health care provider
where the patient's continued care is contingent upon their receipt. The
licensee shall not refuse to provide a patient record on the grounds that the
patient owes the licensee an unpaid balance if the record is needed by another
health care professional for the purpose of rendering care.
(f) Where a third party or entity
has requested examination or an evaluation of a person for a purpose unrelated
to care by the examiner and where a report of the examination is to be supplied
to the third party, the licensee rendering those services shall prepare
appropriate records and maintain their confidentiality, except to the extent
provided by this section. The licensee's report to the third party relating to
the patient shall be made part of the record. The licensee shall:
1. Assure that the scope of the report is
consistent with the request, to avoid the unnecessary disclosure of diagnoses
or personal information which is not pertinent;
2. Forward the report to the individual
entity making the request and in accordance with the terms of the patient's
authorization; if no specific individual is identified, the report should be
marked "Confidential"; and
3.
Should the examination disclose abnormalities or conditions not known to the
patient, the licensee shall advise the patient to consult another health care
professional for treatment.
(g) If a licensee ceases to engage in
practice or it is anticipated that he or she will remain out of practice for
more than three months, the licensee or a designee shall:
1. Establish a procedure by which patients
can obtain patient records or acquiesce in the transfer of those records to
another licensee or health care professional who is assuming the
responsibilities of that practice;
2. If the practice is unattended by another
licensee, publish a notice of the cessation and the established procedure for
the retrieval of records in a newspaper of general circulation in the
geographic location of the licensee's practice, at least once each month for
the first three months after the cessation;
3. File a notice of the established procedure
for the retrieval of records with the Board of Chiropractic Examiners;
and
4. Make reasonable efforts to
directly notify any patient treated during the six months preceding the
cessation in order to provide information concerning the established procedure
for the retrieval of records.
