4734-8-04 Documentation and record keeping.

(A) Chiropractic physicians shall maintain proper, accurate, and legible records in the English language documenting each patient's care. If non-standard codes or abbreviations are used, a key for interpreting this information shall be included in the file.

(B) Each patient's health care record shall include documentation of all services performed in the chiropractic physician's office.

(C) All diagnostic studies performed or ordered by a chiropractic physician shall be documented in the patient's health care record. A report shall accompany each diagnostic procedure performed by the chiropractic physician.

(D) Records, including x-ray films shall be maintained on site for current patients and may be stored off-site for former patients. Records shall be maintained in a safe, confidential, and secure location. Patient records shall be destroyed in a confidential manner, such as shredding or burning, and the records retention schedule is as follows:

(1) Five years beyond when a patient either terminates care or is discharged from care by the chiropractic physician;

(2) Records pertaining to minors shall be maintained for two years beyond the minor's eighteenth birthday, or five years from the termination of care, whichever is longer;

(3) Records which contain information pertinent to contemplated or ongoing legal proceedings which the chiropractic physician has knowledge or notice of shall be kept for two years beyond the conclusion of the legal proceedings, or five years from the termination of care, whichever is longer;

(4) Radiographs (x-rays) over five years old may be destroyed, or in the case of minors, shall be maintained for two years beyond the minor's eighteenth birthday, or for five years after taken, whichever is longer.

(E) Patient records are the responsibility of the treating chiropractic physician. If the chiropractic physician was the employee of another chiropractic physician, then the records belong to the employer. However, if a corporation or another entity employed the chiropractic physician, the Ohio licensed chiropractic physician who is the majority owner of the corporation or entity owns the records and is responsible for their custody and disposition.

(F) Chiropractic physicians shall release patient records pursuant to sections 3701.74 to 3701.742 of the Revised Code.

(G) A chiropractic physician who wishes to close his or her practice shall comply with the provisions outlined in rule 4734-8-07 of the Administrative Code. If a chiropractic physician dies, becomes incapacitated or otherwise unable to practice, his or her executor, guardian, administrator, conservator, next of kin, or other legal representative shall endeavor to comply with the provisions outlined in rule 4734-8-07 of the Administrative Code. In either case, the chiropractic physician, executor, guardian, administrator, conservator, next of kin, or other legal representative, or probate court shall notify the board of the location of the patient files. Any person who takes custody of chiropractic patient records is bound to protect the safety, security, and confidentiality of those records.

Effective: 04/05/2009
R.C. 119.032 review dates: 11/07/2008 and 04/05/2014
Promulgated Under: 119.03
Statutory Authority: 4734.10
Rule Amplifies: 4734.31
Prior Effective Dates: 5/2/03, 8/1/07