12 AAC 40.940. Standards of practice for record keeping

(a) A physician or physician assistant licensed by the board shall maintain adequate records for each patient for whom the licensee performs a professional service.

(b) Each patient record shall meet the following minimum requirements:

(1) be legible;

(2) contain only those terms and abbreviations that are or should be comprehensible to similar licensees;

(3) contain adequate identification of the patient;

(4) indicate the dates that professional services were provided to the patient;

(5) reflect what examinations, vital signs, and tests were obtained, performed, or ordered concerning the patient and the findings and results of each;

(6) indicate the chief complaint of the patient;

(7) indicate the licensee's diagnostic impressions of the patient;

(8) indicate the medications prescribed for, dispensed to, or administered to the patient and the quantity and strength of each medication;

(9) reflect the treatment provided to or recommended for the patient;

(10) document the patient's progress during the course of treatment provided by the licensee.

(d) Each patient record shall include any writing intended to be a final record. This subsection does not require the maintenance of preliminary drafts, notes, other writings, or recordings once this information is converted to final form and placed in the patient record.

History: Eff. 6/15/2001, Register 158

Authority: AS 08.64.100

AS 08.64.107

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