4 CCR 749-1.12 - Record-keeping and patient records
The purpose of this Rule is to clarify additional record-keeping and patient record management requirements as described in sections 12-250-112 and 12-250-117(1)(a), C.R.S.
A. Documentation of the
patient's health history (including pregnancy status, as applicable),
presenting complaint(s), examination, diagnoses, prognoses, treatment
recommendations, treatment, progression of care, prescriptions, lab results,
xrays, correspondence, reports, and any health insurance records must be
maintained in the patient record.
B. Patient records are required to be
contemporaneous, legible, utilize standard medical terminology or
abbreviations, identify the patient, indicate all services rendered during each
patient encounter, identify the provider of service, and indicate the date the
service was performed. Any addition or correction to the patient record after
entry shall be signed and dated by the person making the addition or
correction.
C. Patient records
shall be maintained for a minimum of seven years after the last date of
treatment or examination, or at least two years after the patient reaches the
age of eighteen, whichever occurs later. If patient records are maintained
electronically, then a back-up and data recovery system must be in
place.
D. When the destruction
cycle for patient records is imminent, written notice to the patient's last
known address, or notice by publication, must be made sixty days prior to
destruction allowing a thirty day period wherein the patient may claim his/her
records. When a patient claims such records, the records must be provided to
the patient, or legal guardian, at no charge; however, recovery of appropriate
postage and handling costs is permitted.
E. Patient records shall be destroyed in a
manner that totally obliterates all information contained in the record such as
by incinerating or shredding.
F.
Patient records may not be withheld for outstanding/past due professional fees.
A reasonable fee for copying records may be assessed to the requesting
party.
Notes
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