1. A. In this chapter, the following terms have the meanings indicated.

2. B. Terms Defined.

   1. (1) “Board” means the Maryland Board of Chiropractic Examiners.
   2. (2) “Diagnosis” means the determination by the chiropractor of the nature and cause of a disease or injury through evaluation of patient history, examination, and review of any laboratory and radiological data.
   3. (3) “Examination” means varied procedures such as analysis, assessment, and evaluation performed by the chiropractor to determine a diagnosis.
   4. (4) "History" means the patient's account of past, present, and familial health.

   5. (5) “Subjective, objective, assessment, and plan (SOAP) notes” means the written record maintained by the chiropractor of:

      1. (a) The patient's qualitative or quantitative description of the patient's condition;
      2. (b) Findings pertaining to the patient's condition based on examination and tests;
      3. (c) The chiropractor's clinical opinion of the condition; and
      4. (d) Instructions given to the patient, orthopedic appliances provided to the patient with instructions for usage, and recommendations for treatment, including modalities used and areas treated.

Authority: Health Occupations Article, §3-205, Annotated Code of Maryland

Effective date: February 23, 1998 (25:4 Md. R. 244)

Regulation .02B amended effective June 13, 2011 (38:12 Md. R. 705)

Regulation .03B amended effective October 22, 2007 (34:21 Md. R. 1915)

Chapter and Subtitle renamed and recodified from COMAR 10.43.15 to COMAR 10.43.14, Board of Chiropractic Examiners, Record Keeping, effective January 2, 2017 (43:26 Md. R. 1446)

Regulation .03C amended effective December 30, 2019 (46:26 Md. R. 1165)

Regulation .04A amended effective December 30, 2019 (46:26 Md. R. 1165)