18VAC90-70-230. Medical records.
The prescriber shall keep current, accurate, and complete records in an accessible manner and readily available for review to include:
1. The medical history and physical examination;
2. Past medical history;
3. Applicable records from prior treatment providers or any documentation of attempts to obtain those records;
4. Diagnostic, therapeutic, and laboratory results;
5. Evaluations and consultations;
6. Treatment goals;
7. Discussion of risks and benefits;
8. Informed consent and agreement for treatment;
9. Treatments;
10. Medications, including date, type, dosage and quantity prescribed, and refills;
11. Patient instructions; and
12. Periodic reviews.
Statutory Authority
§§ 54.1-2400 and 54.1-2957.04 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 40, Issue 10 eff. January 31, 2024.