Section 29-6410. TREATMENT OF RECORDS

 

6410.1Each provider shall maintain accurate records reflecting treatment, evaluation, and management services. The record for each recipient shall include, but is not limited to, the following information:

 

(a)General information including the patient's name, address, date of birth, demonstration recipient 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)Initial certification and annual re-certifications;

 

(e)Plan of care;

 

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

 

(g)Recommendations for and referrals to other sources of care;

 

(h)Bill of Rights and Responsibilities;

 

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

 

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

 

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

 

6410.2Each provider shall allow designated personnel of the DOH, HAA, and other authorized agents of the District of Columbia government and the federal government full access to the records for audit purposes.

 

6410.3All providers shall maintain for a period of six (6) years a complete copy of the recipient's treatment record.

 

6410.4Each recipient's treatment record shall include written documentation of the recipient's treatment needs and services. The documentation shall be written so that it is easily understood by a lay person.

 

source

Emergency Rulemaking published at 51 DCR 5605 (May 28, 2004) [EXPIRED]; as amended by Final Rulemaking published at 51 DCR 7435 (July 30, 2004).