77 Ill. Adm. Code 946.320
Records Maintained by the Health Care Professional and Department
Section 946.320Â Records Maintained by the Health Care
Professional and Department
A health care professional certifying the use of medical
cannabis by a qualifying patient shall establish a medical record for the
qualifying patient with regard to the patient's medical condition and continued
treatment for the condition or conditions under the health care professional's
care.
The certifying health care professional shall maintain a
record-keeping system for all patients for whom the certifying health care
professional has recommended the use of medical cannabis. These records shall
be accessible to and subject to review by the Departments of Public Health and
Financial and Professional Regulation upon request.
(Section 35 of the Act)
These records do not need to be maintained separately from the established
records the certifying health care professional maintains on the patient during
the course of the ongoing bona-fide health care professional-patient relationship.
a)Â Â Â Â Â Â Â Â In
addition to records required to be maintained pursuant to the applicable
federal and State statutes and all applicable rules, the records shall
accurately reflect the evaluation and treatment of the qualifying patient, and
shall include the following as applicable:
1)Â Â Â Â Â Â Â Â The patient's name and
the date or dates of visits and treatment;
2)Â Â Â Â Â Â Â Â The patient's medical
history and updated health history;
3)Â Â Â Â Â Â Â Â Documented
results of a full assessment of the patient's medical history, including review
of medical records from other treating health care professionals from the
previous 12 months;
4)Â Â Â Â Â Â Â Â A description of the
patient's current medical condition;
5)Â Â Â Â Â Â Â Â Documented
results of the certifying health care professional's physical examination of
the patient;
6)Â Â Â Â Â Â Â Â A treatment plan;
7)Â Â Â Â Â Â Â Â General consent for
treatment;
8)Â Â Â Â Â Â Â Â Diagnosis and treatment
rendered;
9)Â Â Â Â Â Â Â Â A
list of the drugs prescribed, administered and dispensed, and the quantity of
the drugs;
10)Â Â Â Â Â Â Â Â Radiographs
and diagnostic tests;
11)Â Â Â Â Â Â Â Â Patient
financial and billing records;
12)Â Â Â Â Â Â Â Â The
name of the certifying health care professional and any assistive personnel
providing services; and
13)Â Â Â Â Â Â Â Â Laboratory
results.
b)Â Â Â Â Â Â Â Â The
records for each qualifying patient for whom the health care professional has
certified medical cannabis usage shall be kept for a minimum of three years
after the certifying health care professional last sees the patient.
c)Â Â Â Â Â Â Â Â The Department
will maintain a confidential record of each certifying health care professional
for the purpose of monitoring compliance with the Act. This confidential
record will not be subject to requests under the Freedom of Information Act.