- A. Clinical records shall contain sufficient information to identify the patient clearly, to support the diagnosis, to justify the treatment plan, and to document the results accurately.
B. A clinical record shall be established for every person admitted to a day treatment program and shall include:
- (1) Identifying information, including names, current addresses, and telephone numbers of the patients, relatives, or guardians;
- (2) Presenting problem, the results of mental and physical examinations, diagnosis, treatment plan, a record of the implementation of the treatment plan, and the discharge disposition and referrals;
- (3) Evidence of appropriate release-of-information procedures and informed consent, if applicable.
- C. A system of identification and filing of clinical records shall be maintained to facilitate the prompt location of the patient's clinical record.
- D. Provision shall be made for storing records to assure their security and to maintain their confidentiality.
- E. The record shall be retained for at least 3 years after the discharge of a patient unless the patient is a minor. In that case, it shall be retained for at least 3 years past the date on which the minor would reach the age of majority. Record retention by State or State-funded programs shall conform to the requirements of the records management division.
Authority: Health-General Article, §2-104, Annotated Code of Maryland
Effective date: November 25, 1961
Amended effective August 4, 1965 and April 15, 1974
Chapter revised effective May 29, 1981 (8:11 Md. R. 974)