64B1-10.001. Content and Retention of Medical Records

CHAPTER 64B1-10 ACUPUNCTURE MEDICAL RECORDS 64B1-10.001 Content and Retention of Medical Records 64B1-10.002 Medical Records of an Acupuncturist Who Dies, Terminates His Practice, or Relocates; Retention; Time Limitations 64B1-10.001 Content and Retention of Medical Records. (1) Acupuncturists are required to maintain written medical records for each date of service recording the course of treatment of each patient , which are legible, in English, and consistent with the standards of care in acupuncture. These records must include for each patient at least the following: (a) Patient’s Medical History including current medical diagnosis, medications, allergies, surgeries, implants, prostheses, other medical treatment, and maual therapies doing currently; (b) Acupuncture Diagnostic Impressions, and Treatment Goals and Strategies; (c) Points Used and Each/Any Treatment Procedures Administered at Each Visit, including topical applications; (d) Acupuncturists’ Recommendations; (e) Diet, Lifestyle, Herbal and Dietary Supplement Instructions, when these occur; (f) Dosing and timing of herbs and supplements; (g) Referrals to proper additional medical care; (h) Patient Progress Notes; (i) Laboratory test results when appropriate and medically necessary; (j) Imaging films, reports or test results when appropriate and medically necessary; and (k) Date of service. (2) All medical records must be maintained by the acupuncturist for a period of five (5) years from the date of the last entry to the record.