TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER u: MISCELLANEOUS PROGRAMS AND SERVICES
PART 946 COMPASSIONATE USE OF MEDICAL CANNABIS PATIENT REGISTRY
SECTION 946.320 RECORDS MAINTAINED BY THE PHYSICIAN AND DEPARTMENT
Section 946.320 Records Maintained by the Physician and Department
A physician certifying the use of medical cannabis by a qualifying patient shall establish a medical record for the qualifying patient with regard to his or her medical condition and his or her continued treatment for the condition or conditions under the physician's care. The physician shall maintain a record-keeping system for all patients for whom the physician has recommended the use of medical cannabis. These records shall be accessible to and subject to review by the Departments of Public Health and Financial and Professional Regulation upon request. (Section 35 of the Act) These records do not need to be maintained separately from the established records the physician maintains on the patient during the course of the ongoing bona-fide physician-patient relationship.
a) In addition to records required to be maintained pursuant to the Medical Practice Act of 1987 and all applicable rules, the records shall accurately reflect the evaluation and treatment of the qualifying patient, and shall include the following as applicable:
1) The patient's name and the date or dates of visits and treatment;
2) The patient's medical history and updated health history;
3) Documented results of a full assessment of the patient's medical history, including review of medical records from other treating physicians from the previous 12 months;
4) A description of the patient's current medical condition;
5) Documented results of the physician's physical examination of the patient;
6) A treatment plan;
7) General consent for treatment;
8) Diagnosis and treatment rendered;
9) A list of the drugs prescribed, administered and dispensed, and the quantity of the drugs;
10) Radiographs and diagnostic tests;
11) Patient financial and billing records;
12) The name of the physician or assistive personnel providing services; and
13) Laboratory results.
b) The records for each qualifying patient for whom the physician has certified medical cannabis shall be kept for a minimum of three years after the physician last sees the patient.
c) The Department will maintain a confidential record of each certifying physician for the purpose of monitoring compliance with the Act. This confidential record will not be subject to requests under the Freedom of Information Act.