1. 1. The medical history and physical examination;
2. 2. Past medical history;
3. 3. Applicable records from prior treatment providers or any documentation of attempts to obtain those records;
4. 4. Diagnostic, therapeutic, and laboratory results;
5. 5. Evaluations and consultations;
6. 6. Treatment goals;
7. 7. Discussion of risks and benefits;
8. 8. Informed consent and agreement for treatment;
9. 9. Treatments;
10. 10. Medications (including date, type, dosage, and quantity prescribed and refills);
11. 11. Patient instructions; and
12. 12. Periodic reviews.

The prescriber shall keep current, accurate, and complete records in an accessible manner readily available for review to include:

Statutory Authority

§§ 54.1-2400 and 54.1-2928.2 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 34, Issue 23, eff. August 8, 2018.