C.M.R. 10, 144, ch. 101, ch. X, § 144-101-X-4, subsec. 144-101-X-4.07

Current through 2024-51, December 18, 2024

Subsection 144-101-X-4.07 - ENROLLEE'S RECORDS

There shall be a specific record for each Enrollee which shall include, but not necessarily be limited to:

A. The Enrollee's name, address, and birth date;

B. The Enrollee's medical and social history, including immunization records, as appropriate;

C. A description of the findings from the physical examination;

D. Long and short range medical goals, as appropriate;

E. A description of any tests ordered and performed and their results;

F. A description of treatment, counseling, or follow-up care provided and the dates scheduled for revisits;

G. Notation of any medications and/or supplies dispensed or prescribed;

H. Recommendations for and referral to other sources of care;

I. The dates on which all services were provided; and

J. Written progress notes, which shall identify the services provided.

Other qualified staff (woman's specialists, educators, etc.) may sign record entries relative to history-taking, updates, instruction, and pregnancy testing and results.

Entries are required for each date of service billed and must include the name, title, and signature of the service provider.

C.M.R. 10, 144, ch. 101, ch. X, § 144-101-X-4, subsec. 144-101-X-4.07