201 Ky. Admin. Regs. 21:100

Current through Register Vol. 51, No. 6, December 1, 2024

Section 201 KAR 21:100 - Minimum standards for recordkeeping or itemized statements

RELATES TO: KRS 312.019(9)(j)

NECESSITY, FUNCTION, AND CONFORMITY: KRS 312.019(9)(j) authorizes the board to promulgate administrative regulations to establish minimum standards for recordkeeping and issuance of itemized statements. This administrative regulation establishes standards for recordkeeping and issuance of itemized statements.

Section 1. Office Visits; Recordkeeping.

(1) The patient's records shall include the initial history, exams, re-exams, diagnosis, update diagnosis, standing orders or plan of care (updated as needed or at re-exam), and appropriate diagnostic and imaging studies. This information shall be legibly recorded in the patient's records and properly identified.

(2) Legible documentation, whether electronically generated, computer generated, typewritten, or hand written, shall record each visit, and shall include:

(a) Date of the visit;

(b) Patient name, symptoms and findings, comment and interval history, if any;

(c) Procedures performed, if any;

(d) Additional pertinent comments, instructions, or orders;

(e) The treating doctor's name; and

(f) The name and relationship to the patient of any other person present during any portion of the examination.

Section 2. Requests for Records. Requests for office records, or itemized statements, including dates, services and fees, shall be honored within ten (10) business days of receipt of the request.

Section 3. Record Maintenance. All patient records shall be maintained for a minimum of seven (7) years.

201 KAR 21:100

19 Ky.R. 1243; Am. 1532; eff. 12-16-1992; 32 Ky.R. 1745; 33 Ky.R. 1075; eff. 10-18-2006; 40 Ky.R. 1423; eff. 3-20-2014; 48 Ky.R. 110; eff. 11-23-2021.

STATUTORY AUTHORITY: KRS 312.019