201 KAR 21:100. Minimum standards for recordkeeping or itemized statements.


      RELATES TO: KRS 312.019(9)(j)


      NECESSITY, FUNCTION, AND CONFORMITY: KRS 312.019(9)(j) authorizes the board to promulgate administrative regulations to establish minimum standards for recordkeeping and issuance of itemized statements. This administrative regulation establishes standards for recordkeeping and issuance of itemized statements.


      Section 1. Office Visits; Recordkeeping. (1) The patient's records shall include the initial history, exams, reexams, diagnosis, update diagnosis, standing orders or plan of care (updated as needed or at reexam), and appropriate diagnostic and imaging studies. This information shall be legibly recorded in the patient's records and properly identified.

      (2) Legible documentation, whether electronically generated, computer generated, typewritten, or hand written, shall record each visit, and shall include:

      (a) Date of the visit;

      (b) Patient symptoms and findings, comment and interval history, if any;

      (c) Procedures performed, if any;

      (d) Additional pertinent comments, instructions, or orders; and

      (e) The treating doctor's name.


      Section 2. Itemized Statements. Requests for itemized statements, including dates, services and fees, shall be honored within ten (10) business days.


      Section 3. Record Maintenance. All patient records shall be maintained for a minimum of seven (7) years. (19 Ky.R. 1243; Am. 1532; eff. 12-16-92; 32 Ky.R. 1745; 33 Ky.R. 1075; eff. 10-18-2006; 40 Ky.R. 1423; eff. 3-20-2014.)