Section 12 AAC 40.940 - Standards of practice for record keeping(a) A physician or physician assistant licensed by the board shall maintain adequate records for each patient for whom the licensee performs a professional service.(b) Each patient record shall meet the following minimum requirements: (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 dates that professional services were provided to the patient;(5) reflect what examinations, vital signs, and tests were obtained, performed, or ordered concerning the patient and the findings and results of each;(6) indicate the chief complaint of the patient;(7) indicate the licensee's diagnostic impressions of the patient;(8) indicate the medications prescribed for, dispensed to, or administered to the patient and the quantity and strength of each medication;(9) reflect the treatment provided to or recommended for the patient;(10) document the patient's progress during the course of treatment provided by the licensee.(c) Each entry in the patient record shall reflect the identity of the individual making the entry.(d) Each patient record shall include any writing intended to be a final record. This subsection does not require the maintenance of preliminary drafts, notes, other writings, or recordings once this information is converted to final form and placed in the patient record.(e) The patient records for a physician or physician assistant practicing under AS 08.64.364 must comply with the requirements of this section and include (1) the physical location of the patient and the physician or physician assistant when the patient care was provided; (2) a description of the method of the communication between the physician or physician assistant and patient;(3) the name, location, and phone number, state of Iicensure and license number of the physician, physician assistant or other licensed health care provider available to provide follow-up care; and(4) if the prescribing physician or physician assistant is not the patient's primary care provider, documentation of the patient's consent to sending a copy of all records of the encounter to the patient's primary care provider, and if the patient consents, confirmation that the records were sent to the patient's primary care provider.Eff. 6/15/2001, Register 158; am 10/8/2017, Register 224, January 2018; am 3/25/2020, Register 233, April 2020Authority:AS 08.64.100
AS 08.64.107
AS 08.64.364