Md. Code Regs. 10.21.30.08

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.21.30.08 - Medical Records

A. Originating Site. The originating site shall:

(1) Be responsible for maintaining a complete medical record as if the individual were seen face-to-face at the originating site;

(2) Meet the facility and community standard for medical record completion and retention, including applicable record reviews; and

(3) Be responsible for any proper release of information contained in an individual's medical record.

B. Distant Site.

(1) The distant site shall maintain copies of all documentation completed by the distant site TMH provider unless the distant site TMH provider enters the information directly into the originating site's electronic medical record system.

(2) The distant site, as part of its quality improvement system, shall have a process to review TMH care.

(3) As part of quality monitoring, when the originating site's electronic medical records are reviewed at the distant site, the:

(a) Review may include the TMH provider's documentation online, if authorized; or

(b) Distant site may request sections of the individual's electronic medical record from the originating site for the distant site peer review.

C. TMH records shall be retained according to the provisions of Health-General Article, §4-403, Annotated Code of Maryland.

Md. Code Regs. 10.21.30.08