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

2. B. A 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. With the patient's consent or to the extent that information in a record is necessary for a patient's care in an emergency transfer, the facility shall:

   1. (1) Send a copy of the medical record with the patient on:

      1. (a) Referral to another physician or other licensed health professional; or
      2. (b) Transfer to a hospital;
   2. (2) If appropriate, and with the patient's consent, use the medical record when 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, §20-209, Annotated Code of Maryland

Effective date: July 23, 2012 (39:14 Md. R. 835)