Current through Register Vol. 49, No. 7, August 12, 2024
Part 4770.4017 - RECORDS MAINTAINED BY THE CERTIFYING HEALTH CARE PRACTITIONERSubpart 1.Health records maintained.The health care practitioner must maintain a health record for each patient for whom the health care practitioner has certified a qualifying medical condition. These records need not be maintained separately from the health care practitioner's established records for the ongoing medical relationship with the patient.
Subp. 2.Contents.The records must be legible, accurately reflect the patient's evaluation and treatment, and must include the following:
A. the patient's name and dates of visits and treatments;B. the patient's case history as it relates to the qualifying condition;C. the patient's health condition as determined by the health care practitioner's examination and assessment;D. the results of all diagnostic tests and examinations as they relate to the qualifying condition; and any diagnosis resulting from the examination;E. the patient's plan of care, which must state with specificity the patient's condition, functional level, treatment objectives, medical orders, plans for continuing care, and modifications to that plan; andF. a list of drugs prescribed, administered and dispensed, and the quantity of the drugs.Subp. 3.Retention.The health care practitioner must keep records for each qualifying patient for at least three years after the last patient visit, or seven years, whichever is greater.