Rule 4734-8-04 | Documentation and record keeping.
(A) Every licensee must maintain proper, accurate, and legible records documenting each patient's care. If non-standard codes or abbreviations are used, a key for interpretation must be included in the file. All documentation must be in the English language.
(B) Each patient's health care record shall include all services rendered including but not limited to:
(1) Date(s) of treatment;
(2) Examinations;
(3) X-ray reports;
(4) Referrals;
(5) Diagnostic studies performed and/or ordered accompanied by a report of the results of each procedure performed or ordered;
(6) Diagnosis or clinical impression and clinical treatment plan provided to the patient.
(C) Health care records, including x-ray films must be maintained on site for current patients and may be stored off-site for former patients.
(D) Health care records must be maintained in a safe, confidential, and secure location.
(E) Health care records must be destroyed in a confidential manner, such as shredding or burning.
(F) Health care records must be retained for five years from the last date of clinical encounter, termination of care, or dismissal from care.
(G) Health care records pertaining to minors must be maintained for two years beyond the minor's eighteenth birthday, or five years from the last date of clinical encounter, whichever is longer.
(H) Health care records containing information pertinent to contemplated or ongoing legal proceedings which the licensee has knowledge or notice of must 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.
(I) Health care records must be released pursuant to sections 3701.74 to 3701.742 of the Revised Code.
Last updated December 29, 2025 at 7:48 AM
Supplemental Information