Section 5.51. Patient records

(a) A licensee shall maintain a patient record for each patient which accurately reflects the licensee’s evaluation and treatment of the patient. Entries in the patient record shall be made in a timely fashion.

(b) The patient record shall contain the patient’s full name, address, date of birth, sex and other information sufficient to identify the patient, the date of every entry in the patient record and the name of the person making an entry if that person is not the licensee.

(c) The patient record shall contain sufficient information to document the clinical necessity for chiropractic care rendered, ordered or prescribed.

(d) A referral to another health care provider shall be reported in the patient record.

(e) A licensee shall retain a patient record for at least 7 years from the date of the last chiropractic service for which a patient record entry is required. A licensee shall retain the patient record for a minor patient until 1 year after the minor patient reaches majority, even if this means that the licensee retains the record for more than 7 years.

The provisions of this § 5.51 adopted December 27, 1991, effective December 28, 1991, 21 Pa.B. 5944.

Notation

Authority

The provisions of this § 5.51 issued under section 302 of the Chiropractic Practice Act (63 P. S. § 625.302).

Cross References

This section cited in 49 Pa. Code § 5.51a (relating to patient records—statement of policy).