1. A. The facility shall maintain a complete, comprehensive, and accurate medical record for each patient.

2. B. Each patient's medical record shall include at least the following:

   1. (1) Patient identifier;
   2. (2) Significant medical history and results of a physical examination;
   3. (3) Documentation of care or services provided;
   4. (4) Evidence of consent; and
   5. (5) Discharge diagnosis.

3. C. The facility shall:

   1. (1) Send a copy of the medical record with the patient on referral to another health care provider or on transfer to a hospital;
   2. (2) Use the medical record, if appropriate, in instructing the patient and the family; and
   3. (3) Comply with all disclosure requirements as set forth in Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland.

Authority: Health-General Article, §19-3B-01 et seq., Annotated Code of Maryland

Effective date: August 23, 1999 (26:17 Md. R. 1322)

Regulation .02B amended effective April 16, 2012 (39:7 Md. R. 491)

Regulation .04A, I amended effective March 13, 2017 (44:5 Md. R. 292)

Regulation .05A amended effective March 14, 2016 (43:5 Md. R. 385)

Regulation .08 amended effective April 16, 2012 (39:7 Md. R. 491)

Regulation .08C amended effective February 27, 2017 (44:4 Md. R. 252)