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. 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, Title 19, Subtitle 3C, Annotated Code of Maryland

Effective date: July 1, 2015 (41:24 Md. R. 1427)

Regulation .01B amended effective March 30, 2026 (53:6 Md. R. 291)