§ 45.101. Preparing, maintaining and retaining records.
(a) A licensee shall maintain a record for each person served which accurately, legibly and completely reflects the evaluation or treatment of that person. A record shall be prepared and retained irrespective of whether treatment is actually rendered or whether a fee is charged. The record shall include, at a minimum:
(1) The name and address of the person served and, if that person is a minor, the name of the parent or guardian.
(2) The date of each visit by the person served.
(3) A description of the complaint, symptoms and diagnosis of the person served.
(4) A description of the treatment or service rendered at each visit and the identity of the licensee or assistant rendering it.
(5) The date of each entry into the record bearing on evaluation or treatment and the signature of the licensee.
(b) A licensee shall retain records for a person served for a minimum of 7 years from the date of the last entry. A licensee shall retain and store the records in a safe location to maintain confidentiality.
(c) A licensee shall comply with a written, dated and signed transfer of records request from a person served, or from that person’s parent or guardian if the person is a minor within a reasonable period of time upon receipt of the request. A legible copy of the record shall be provided either gratuitously or at a charge which reflects the licensee’s cost of duplicating and forwarding the record.
(d) A licensee’s failure to comply with this section will be considered unprofessional conduct under § 45.103 (relating to unprofessional conduct) and will subject the noncomplying licensee to disciplinary action under section 5(4) of the act (63 P. S. § 1705(4)).
(e) This section does not apply to licensees acting within the scope of their employment under section 6(b)(2) of the act (63 P. S. § 1706(b)(2)).
Cross References This section cited in 49 Pa. Code § 45.103 (relating to unprofessional conduct).
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