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 or ordered 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 retained as follows:

(1) Five years from the last date of clinical encounter when a patient either terminates care or is dismissed 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 last date of clinical encounter, whichever is longer;

(3) Records containing 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 last date of clinical encounter, whichever is longer;

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

Effective: 05/25/2014
R.C. 119.032 review dates: 03/10/2014 and 05/25/2019
Promulgated Under: 119.03
Statutory Authority: 4734.10
Rule Amplifies: 4734.31
Prior Effective Dates: 5/2/03, 8/1/07, 4/5/09