Chiropractic Record-keeping

(1) A chiropractor shall establish and maintain a separate, adequate and accurate written clinical record for each patient in his or her care. The record shall be kept in chronological order and record entries shall be made contemporaneously. Each such entry shall be signed by, or shall otherwise adequately identify, the registered chiropractor who is treating the patient to whom the record pertains. Such records shall be legible and self-explanatory. Such records shall include, at a minimum, documentation of the following: (a) The patient's case history; (b) Findings of all examinations performed; (c) Findings of special studies, including but not limited to x-ray studies taken or reviewed; (d) Clinical impression (e) Treatment plan; (f) Informed consent which acknowledges that: 1. the patient has been part of an informed consent process; 2. the patient received sufficient information about the diagnostic or therapeutic procedures which the chiropractor proposes to use; 3. the material risks have been disclosed to the patient, including a description of those risks; and 4. the patient, after assessment, has accepted (or rejected) the procedure or care, understanding the material risks to that procedure. (g) Progress notes for each patient encounter (Subjective and Objective Assessment and Plan format, Data Assessment and Plan format, or similar work chart notes); and (h) Details of supportive procedures or therapies, when administered, dispensed or prescribed. (2) Except as provided in 233 CMR 4.05(3) or (4), 4.16 and 5.06: Inspections clinical records and all information contained therein shall be kept confidential to the extent provided by state or federal law. (3) Upon the written request of the patient, the patient's authorized legal representative, or, in the case of an unemancipated minor patient, the patient's parent or legal guardian, a chiropractor shall furnish a complete copy of that patient's clinical records, including all supporting documentation and reports, to the party authorized to receive it. A reasonable fee may be charged for this service. (4) A chiropractor shall furnish to the Board or its duly authorized representative a complete copy of a Patient Record upon written request promptly and, in no instance, more than 30 days after date of request. No fee may be charged for this service. (5) No patient shall be required to sign any release from liability or waiver as a condition for the receipt of his or her clinical record pursuant to 233 CMR 4.05(3). (6) Violation of any provision of 233 CMR 4.05 shall be considered unprofessional conduct within the meaning of M.G.L. c. 112, § 93, and shall constitute sufficient grounds for disciplinary action by the Board. (7) Record Retention. Patient Records and Business Records shall be stored in a manner that protects them from foreseeable damage or destruction. (a) Patient Records shall be maintained on the premises where Chiropractic Treatment is rendered for each active patient. (b) Business Records shall be maintained for a minimum of seven years. (c) For a patient who is younger than two years old when he or she receives Chiropractic Treatment, Patient Records shall be maintained at least until the patient reaches the age of nine. (d) For a patient who receives Chiropractic Treatment on or after the patient reaches the age of two, Patient Records shall be maintained for a minimum of seven years. (e) Patient or Business Records stored electronically shall have an established system of weekly back-up. Copies of the back-up records shall be delivered weekly to an off-site location, where the back-up copies will be maintained in a safe and secure manner. (8) Upon cessation of his or her practice, a Chiropractor shall transfer all Patient and Business Records, which are less than seven years old to a location where such records may be inspected and copied by patients.