Section 338.12015. Patient records.

(1) A licensee practicing chiropractic in this state shall maintain a legible patient record for each patient, which accurately reflects the licensee's evaluation and treatment of the patient. Entries in the patient record shall be made in a timely fashion.

(2)    The patient record shall contain all of the following:

(a)    The name of the attending chiropractor.

(b)      The patient's full name,  address,  date   of  birth,  sex,   and  other information sufficient to identify the patient.

(c)     The date of every entry in the patient record.

(d)        A patient record entry for an initial patient visit that includes    all of the following:

(i)     History, including description of presenting condition.

(ii)     Physical evaluation.

(iii)     Diagnostic studies, if applicable.

(iv)     Diagnosis.

(v)     Treatment or care provided.

(e)      A patient record entry for subsequent evaluations, treatments, or care provided that includes all of the following:

(i)     Change in condition, if applicable.

(ii)     Physical evaluation.

(iii)     Treatment or care provided.

(f)    If applicable, a referral to another health care provider.

(3)      A licensee shall retain a patient record for at least 7 years from the date of the last chiropractic service for which a patient record entry is required. A licensee shall retain the patient record for a  minor  patient until 1 year after the minor patient reaches 18 years of age,  even  if  this results in the record being retained for more than 7 years.

History: 2006 AACS; 2011 AACS.