3 CCR 713-30.7 - DOCUMENTATION REQUIREMENTS

A. Written Procedure Protocols

1. Written procedure protocols are required to be in place at any time that a delegating physician will not be physically located on the premises where medical services are provided by a delegatee.

2. The delegating physician shall create a comprehensive written protocol for use by the delegatee for each procedure that the physician delegates to the delegatee. The delegating physician may not rely upon a written protocol created by the delegatee to satisfy this requirement.

B. Written Emergency Protocols

1. Written emergency protocols are required to be in place at any time that a delegating physician will not be physically located on the premises where medical services are provided by a delegatee.

2. The delegating physician shall create a comprehensive written emergency protocol for use by the delegatee when medical services result in adverse events. The delegating physician may not rely upon a written protocol created by the delegatee to satisfy this requirement.

3. As part of a written emergency protocol, the delegatee shall be required to notify the delegating physician of all adverse events.

C. Medical Records

1. A delegating physician shall assure that there is a timely medical record for all patient contacts with either the delegatee or with the delegating physician. The medical record prepared by a delegatee shall conform to generally accepted standards of medical practice for recordkeeping.

2. A delegating physician shall review the care provided to every patient who is treated by the delegatee. The delegating physician shall demonstrate that he or she has reviewed the care provided to the patient by reviewing each entry in the patient's medical record. The delegating physician shall initial and date the medical record at the time he or she reviews the record.

3. A delegating physician shall review the care provided to patients pursuant to his or her delegated authority within fourteen days of the date that the care was provided.

4. When the delegated medical services by delegatees occur in the context of a same-day encounter with the delegating physician and the delegating physician has been personally involved in the care of the patient, the delegating physician's own documentation of the encounter shall be adequate to meet the requirements for chart review, and the delegating physician need not co-sign any entries made by the delegatee.

D. Written Agreement between Delegating Physician and Delegatee

1. The delegating physician and the delegatee must have a written agreement documenting and detailing the relationship. This written agreement is attached in Appendix A of these Rules. The written agreement as set forth in Appendix A must be available to the public at the site where the delegated medical services are performed.

2. The delegating physician must maintain a list of all delegatees to whom the physician has delegated medical services. The list must include a comprehensive and specific list of the delegated medical services that the physician has authorized the delegatee to perform.

3. Where the delegating physician is on-site and able to personally direct the delegatee at least 60% of the time, the requirement for a written agreement may be satisfied through job descriptions, personnel records or other documents that identify the relationship between the delegating physician and delegatee.

E. Documentation that the Delegating Physician or Healthcare Facility Must Maintain

1. The delegating physician or healthcare facility shall maintain a copy of all documentation required by these Rules, including but not limited to:

a. Appendix A written agreement;

b. Any agreement that the delegating physician enters into, in order to serve as a medical director.

2. The delegating physician or healthcare facility is required to maintain all documentation required by these Rules.

3. Upon request, the delegating physician is responsible to provide all documentation maintained by the physician or healthcare facility in accordance with these Rules to the Board. The delegating physician may not rely solely on a medical office or other entity to provide the requested documents.

F. Disclosure Requirements to Patients

1. Delegating physicians shall ensure that delegatees adequately disclose that a medical service will be performed by a delegatee, rather than by the delegating physician. When the delegating physician is not actively involved in the patient encounter, the disclosure shall include: the service the patient is receiving is a medical service; the delegatee of the service is not licensed by the state of Colorado or is acting beyond the scope of his or her Colorado license, certification or registration; the delegatee is providing the service pursuant to the delegated authority of a physician; and, the delegating physician is available personally to consult with them or provide appropriate evaluation or treatment in relation to the delegated medical services. Upon request, the delegating physician must timely and personally provide such consultation, evaluation or treatment, or provide appropriate follow-up care and/or referrals.

a. The disclosure requirements may be made in writing as part of a signed disclosure agreement, an Informed Consent agreement, or a Consent or Agreement to Treat form.

2. For all delegated medical services occurring in the context of a bona fide physician-patient relationship, the delegating physician and the delegatee shall document the disclosure made to the patient, at the time each medical service is performed.

3. For all offices at which delegated medical-aesthetic services are provided, the delegating physician shall ensure that each office conspicuously posts, in the office's reception area, a notice with the name and contact information for each delegating physician.

4. For all offices at which delegated medical-aesthetic services are provided, the delegating physician shall create a written disclosure, identifying the service to be performed, that the performance of the medical service is delegated to an unlicensed person, the name of the unlicensed person/delegatee, and the name and contact information for the delegating physician. The written disclosure shall be signed by the patient prior to receiving the medical service. The patient shall be given a copy of each disclosure and a copy shall be retained within the patient's medical record.

5. The delegating physician must ensure that each patient receives all information necessary to give appropriate informed consent or consent or agreement for treatment for any medical service and that such informed consent or consent or agreement for treatment is timely documented in the patient's chart.

Notes

3 CCR 713-30.7

40 CR 10, May 25, 2017, effective 6/14/2017