Patient records required to be maintained, contents--correctionsto records, procedure--obtaining records, procedure.
331.110. 1. Chiropractors shall maintain an adequate and completepatient record for each patient and may maintain electronic recordsprovided that the record-keeping format is capable of being printed forreview by the state board of chiropractic examiners. An adequate andcomplete patient record shall include documentation of the followinginformation:
(1) Identification of the patient including name, birth date,address, and telephone number;
(2) The date or dates the patient was seen;
(3) The current status of the patient including the reason for thevisit;
(4) Observation of pertinent physical findings;
(5) Assessment and clinical impression or diagnosis, to the extentauthorized by section 331.010;
(6) Plan for care and treatment or additional consultations ordiagnostic testing, if necessary, to the extent authorized by section331.010;
(7) Any informed consent for office procedures or tests, to theextent authorized by section 331.010.
2. Patient records remaining under the care, custody, and control ofthe licensee shall be maintained by the licensee of the board or thelicensee's designee for a minimum of seven years from the date of when thelast professional service was provided.
3. Any correction, addition, or change in any patient record mademore than forty-eight hours after the final entry is entered in the recordand signed by the chiropractor shall be clearly marked and identified assuch and the date, time, and name of the person making the correction,addition, or change shall be included as well as the reason for thecorrection, addition, or change.
4. The board shall not initiate disciplinary action under section331.060 against a licensee solely based on a violation of this section. Ifthe board initiates disciplinary action against the licensee for any reasonother than a violation of this section the board may allege violation ofthis section as an additional cause for discipline under section 331.060.
5. The board shall not obtain a medical record of a patient withoutwritten authorization from the patient to obtain the medical record or theissuance of a subpoena for the medical record of the patient.
Patient records required to be maintained, contents--correctionsto records, procedure--obtaining records, procedure.
331.110. 1. Chiropractors shall maintain an adequate and completepatient record for each patient and may maintain electronic recordsprovided that the record-keeping format is capable of being printed forreview by the state board of chiropractic examiners. An adequate andcomplete patient record shall include documentation of the followinginformation:
(1) Identification of the patient including name, birth date,address, and telephone number;
(2) The date or dates the patient was seen;
(3) The current status of the patient including the reason for thevisit;
(4) Observation of pertinent physical findings;
(5) Assessment and clinical impression or diagnosis, to the extentauthorized by section 331.010;
(6) Plan for care and treatment or additional consultations ordiagnostic testing, if necessary, to the extent authorized by section331.010;
(7) Any informed consent for office procedures or tests, to theextent authorized by section 331.010.
2. Patient records remaining under the care, custody, and control ofthe licensee shall be maintained by the licensee of the board or thelicensee's designee for a minimum of seven years from the date of when thelast professional service was provided.
3. Any correction, addition, or change in any patient record mademore than forty-eight hours after the final entry is entered in the recordand signed by the chiropractor shall be clearly marked and identified assuch and the date, time, and name of the person making the correction,addition, or change shall be included as well as the reason for thecorrection, addition, or change.
4. The board shall not initiate disciplinary action under section331.060 against a licensee solely based on a violation of this section. Ifthe board initiates disciplinary action against the licensee for any reasonother than a violation of this section the board may allege violation ofthis section as an additional cause for discipline under section 331.060.
5. The board shall not obtain a medical record of a patient withoutwritten authorization from the patient to obtain the medical record or theissuance of a subpoena for the medical record of the patient.
Patient records required to be maintained, contents--correctionsto records, procedure--obtaining records, procedure.
331.110. 1. Chiropractors shall maintain an adequate and completepatient record for each patient and may maintain electronic recordsprovided that the record-keeping format is capable of being printed forreview by the state board of chiropractic examiners. An adequate andcomplete patient record shall include documentation of the followinginformation:
(1) Identification of the patient including name, birth date,address, and telephone number;
(2) The date or dates the patient was seen;
(3) The current status of the patient including the reason for thevisit;
(4) Observation of pertinent physical findings;
(5) Assessment and clinical impression or diagnosis, to the extentauthorized by section 331.010;
(6) Plan for care and treatment or additional consultations ordiagnostic testing, if necessary, to the extent authorized by section331.010;
(7) Any informed consent for office procedures or tests, to theextent authorized by section 331.010.
2. Patient records remaining under the care, custody, and control ofthe licensee shall be maintained by the licensee of the board or thelicensee's designee for a minimum of seven years from the date of when thelast professional service was provided.
3. Any correction, addition, or change in any patient record mademore than forty-eight hours after the final entry is entered in the recordand signed by the chiropractor shall be clearly marked and identified assuch and the date, time, and name of the person making the correction,addition, or change shall be included as well as the reason for thecorrection, addition, or change.
4. The board shall not initiate disciplinary action under section331.060 against a licensee solely based on a violation of this section. Ifthe board initiates disciplinary action against the licensee for any reasonother than a violation of this section the board may allege violation ofthis section as an additional cause for discipline under section 331.060.
5. The board shall not obtain a medical record of a patient withoutwritten authorization from the patient to obtain the medical record or theissuance of a subpoena for the medical record of the patient.
