Section 29-4305. TREATMENT RECORDS

 

4305.1Each provider shall maintain accurate records reflecting treatment, evaluation and management services. The record for each patient shall include, but is not limited to, the following information:

 

(a)General information including the patient's name, address, date of birth, Medicaid identification number, telephone number and telephone number of emergency contact person;

 

(b)Medical information, including medical and social history, results of the initial physical examination and any other follow-up exams;

 

(c)A description of any tests ordered and their results;

 

(d)A description of treatment and follow-up care, including the dates of scheduled revisits;

 

(e)Recommendations for and referral to other sources of care;

 

(f)Dates on which services are provided;

 

(g)Signed and dated progress notes, which identify the services provided;

 

(h)Evidence of written consent to treatment or documentation of refusal to consent to any treatment, evaluation or management services;

 

(i)Copies of surgical reports, including a narrative description of the surgery performed. If reconstructive breast surgery is performed, the surgeon shall document the basis of his or her opinion that reconstructive surgery was necessary to correct a disfigurement caused by the removal of a breast or breasts; and

 

(j)Documentation of the treatment, evaluation and management of each determination of an emergency medical condition.

 

4305.2Each provider shall establish procedures for safeguarding patient's information pursuant to 42 CFR 431.305 and shall ensure that, except as otherwise provided by federal or District la w or rules, the use or disclosure of patient information shall be restricted to purposes related to the administration of the Medicaid Program, as set forth in 42 CFR 431.302.

 

4305.3Each provider shall allow appropriate personnel of the Department of Health and other authorized agents of the District of Columbia government and the federal government full access to the records for audit purposes.

 

source

Final Rulemaking published at 50 DCR 997 (January 31, 2003).