Current through Register Vol. 63, No. 3, March 1, 2024
(1) Failure to keep complete, accurate, and
minimally competent medical and billing records on all patients may result in
discipline.
(2) Licensee Duty to
Maintain Clear, Legible, Complete, Accurate, and Minimally Competent Medical
Records. Medical records shall contain the following:
(a) Clear, legible, complete, and accurate
information as to allow any other physician or treatment provider to understand
the nature of that patient's case and to be able to follow up with the care of
that patient, if necessary;
(b)
Completed initial intake form in each patient's medical record or chart. New
patient information must contain date of visit, current legal name, date of
birth, gender identification, contact information, presenting problem (i.e.
reason for doctor visit), health history, allergies and medications currently
taking;
(c) Each page shall include
patient name, date of birth, date of service, and licensee of record. Entries
made by persons other than the licensee must be signed by the person making the
entry and then co-signed by the licensee;
(d) Description of the chief complaint or
primary reason the patient sought treatment from the licensee;
(e) Documentation of any reported changes in
patient health history which affects the chief complaint or the general history
of the health of the patient;
(f)
An accurate record of the diagnostic and therapeutic information that supports
patient care, including but not limited to:
(A) Clinically indicated vitals at the time
of examination. If examination is via telemedicine, vitals may be reported by
the patient, as clinically indicated.
(B) Examinations and the results of those
examinations;
(C)
Diagnoses;
(D) All pertinent
information to support patient care; treatment plan, patient response to
treatment, and any subsequent changes to the treatment plan, and the clinical
reasoning for those changes;
(E)
All medications prescribed by licensee, including over the counter medications,
supplements, as well as dose and duration of medication;
(F) Any specific concerns of the licensee;
including lack of adherence with the treatment plan;
(G) Documentation of informing patient of
risk and permission to treat, as clinically indicated.
(H) Other clinically relevant correspondence,
including, but not limited to: text, telephonic, electronic or other patient
communications, referrals to other practitioners, and expert reports.
(3) Licensee Duty to
Maintain and Retain Patient Medical Records.
(a) If the treating naturopathic physician is
an employee or associate, the duty to maintain entire records shall be with the
business entity or licensed physician that employs or contracts with the
treating naturopathic physician;
(b) Naturopathic physicians providing file
reviews, second opinion consultations, or independent medical examinations
(IME) shall be responsible for keeping an available copy of all authored
reports for six years from the date authored;
(c) The responsibility for maintaining entire
patient records may be transferred to another naturopathic business entity or
to another naturopathic physician as part of a business ownership transfer
transaction;
(d) Except as provided
for in paragraph (3)(a) of this rule, a naturopathic physician who is an
independent contractor or who has an ownership interest in a naturopathic
practice shall provide notice when leaving, selling, or retiring from the
naturopathic office where the naturopathic physician has provided treatment and
services;
(e) Notification shall be
sent to all patients who received services from the naturopathic physician
during the two years immediately preceding the naturopathic physician's last
date for seeing patients. This notification shall be sent no later than thirty
days prior to the last date the naturopathic physician will see patients. The
notice shall include all of the following:
(A)
A statement that the naturopathic physician will no longer be providing
treatment or services at the practice;
(B) The date on which the naturopathic
physician will cease to provide treatment and services; and
(C) Contact information that enables the
patient to obtain the patient's records;
(D) The notice shall be sent in one of the
following ways:
(i) A letter sent through the
US Postal Service to the last known address of the patient with the date of the
mailing of the letter documented, or
(ii) A secure electronic message.
(E) In the event of an emergency
or other unanticipated incident where a naturopathic physician is unable to
provide a thirty day notice as required by paragraph (2)(f) of this rule, the
naturopathic physician shall provide such notice within thirty days after it is
determined that the physician will not be returning to practice.
(F) A naturopathic physician shall establish
a plan for custodianship of these records in the event they are incapacitated,
become deceased, are or will become unable to maintain these records pursuant
to paragraph.
(4) A patient's entire health care record
shall be kept by the naturopathic physician a minimum of six years from the
date of last treatment. However, if a patient is a minor, the records must be
maintained at least six years from the time they turn 18 years of
age.
(5) Disposal of all records
shall be completed by a process that results in permanent destruction of the
records and shall be compliant with all state and federal law.