Kan. Admin. Regs. § 100-76-9

Current through Register Vol. 43, No. 24, August 22, 2024

Section 100-76-9 - Patient records; adequacy

(a) Each licensed acupuncturist shall maintain an adequate record for each patient for whom the licensee performs a professional service.

(b) Each patient record shall meet the following requirements:

(1) Be legible;

(2) contain only those terms and abbreviations that are or should be comprehensible to similar licensees;

(3) contain adequate identification of the patient;

(4) indicate the date on which each professional service was provided;

(5) contain all clinically pertinent information concerning the patient's condition;

(6) document what examinations, vital signs, and tests were obtained, performed, or ordered and the findings and results of each;

(7) specify the patient's initial reason for seeking the licensee's services and the initial diagnosis;

(8) specify the treatment performed or recommended;

(9) document the patient's progress during the course of treatment provided by the licensee; and

(10) include all patient records received from other health care providers, if those records formed the basis for a treatment decision by the licensee.

(c) Each entry shall be authenticated by the person making the entry, unless the entire patient record is maintained in the licensee's own handwriting.

(d) Each patient record shall include any writing intended to be a final record, but shall not require the maintenance of rough drafts, notes, other writings, or recordings once this information is converted to final form. The final form shall accurately reflect the care and services rendered to the patient.

(e) For purposes of the act and this regulation, an electronic patient record shall be deemed to be a written patient record if both of the following conditions are met:

(1) Each entry in the electronic record is authenticated by the licensee.

(2) No entry in the electronic record can be altered after authentication.

Kan. Admin. Regs. § 100-76-9

Authorized by K.S.A. 2017 Supp. 657615; implementing K.S.A. 2017 Supp. 65-7616; effective, T-100-9-21-17, Sept. 21, 2017; amended by Kansas Register Volume 36, No. 52; effective 1/12/2018.