Effective 28 Aug 2004

331.110. Patient records required to be maintained, contents — corrections to records, procedure — obtaining records, procedure. — 1. Chiropractors shall maintain an adequate and complete patient record for each patient and may maintain electronic records provided that the record-keeping format is capable of being printed for review by the state board of chiropractic examiners. An adequate and complete patient record shall include documentation of the following information:

(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 the visit;

(4) Observation of pertinent physical findings;

(5) Assessment and clinical impression or diagnosis, to the extent authorized by section 331.010;

(6) Plan for care and treatment or additional consultations or diagnostic testing, if necessary, to the extent authorized by section 331.010;

(7) Any informed consent for office procedures or tests, to the extent authorized by section 331.010.

2. Patient records remaining under the care, custody, and control of the licensee shall be maintained by the licensee of the board or the licensee's designee for a minimum of seven years from the date of when the last professional service was provided.

3. Any correction, addition, or change in any patient record made more than forty-eight hours after the final entry is entered in the record and signed by the chiropractor shall be clearly marked and identified as such and the date, time, and name of the person making the correction, addition, or change shall be included as well as the reason for the correction, addition, or change.

4. The board shall not initiate disciplinary action under section 331.060 against a licensee solely based on a violation of this section. If the board initiates disciplinary action against the licensee for any reason other than a violation of this section the board may allege violation of this section as an additional cause for discipline under section 331.060.

5. The board shall not obtain a medical record of a patient without written authorization from the patient to obtain the medical record or the issuance of a subpoena for the medical record of the patient.

­­--------

(L. 2004 H.B. 1246)