334.097. Medical records, maintenance of, requirements, contents--corrections, additions, and changes.
Medical records, maintenance of, requirements, contents--corrections,additions, and changes.
334.097. 1. Physicians shall maintain an adequate and completepatient record for each patient and may maintain electronic recordsprovided the record-keeping format is capable of being printed for reviewby the state board of registration for the healing arts. An adequate andcomplete patient record shall include documentation of the followinginformation:
(1) Identification of the patient, including name, birthdate, addressand telephone number;
(2) The date or dates the patient was seen;
(3) The current status of the patient, including the reason for thevisit;
(4) Observation of pertinent physical findings;
(5) Assessment and clinical impression of diagnosis;
(6) Plan for care and treatment, or additional consultations ordiagnostic testing, if necessary. If treatment includes medication, thephysician shall include in the patient record the medication and dosage ofany medication prescribed, dispensed or administered;
(7) Any informed consent for office procedures.
2. Patient records remaining under the care, custody and control ofthe licensee shall be maintained by the licensee of the board, or thelicensee's designee, for a minimum of seven years from the date of when thelast professional service was provided.
3. Any correction, addition or change in any patient record made morethan forty-eight hours after the final entry is entered in the record andsigned by the physician shall be clearly marked and identified as such, andthe date, time and name of the person making the correction, addition orchange shall be included, as well as the reason for the correction,addition or change.
4. A consultative report shall be considered an adequate medicalrecord for a radiologist, pathologist or a consulting physician.
5. The board shall not initiate disciplinary action pursuant tosubsection 2 of section 334.100 against a licensee solely based on aviolation of this section. If the board initiates disciplinary actionagainst the licensee for any reason other than a violation of this section,the board may allege violation of this section as an additional cause fordiscipline pursuant to subdivision (6) of subsection 2 of section 334.100.
6. The board shall not obtain a patient medical record withoutwritten authorization from the patient to obtain the medical record or theissuance of a subpoena for the patient medical record.
(L. 2002 S.B. 1024)