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Summary:

Oral or electronic data transmission prescriptions must be reduced to writing for record keeping.

Summary:

Every employer must file a report with the Department of Industrial Relations of every occupational injury or illness that results in lost time beyond the date of the injury or that requires medical treatment beyond first aid. The reports must the employee's social security number. Insured employers must file with the insurer within five days of learning about the injury. A self-insured employer, the state, or the insurer of an insured employer file within the time prescribed by the administrative director. The administrative director must ensure that the report contains necessary information to continue to be acceptable as substitute documentation for purposes of recordkeeping required under the Occupational Safety and Health Act of 1970. [NB: this version of the statute is only effective upon the adoption of regulations by the administrative director, and as of July 2010, this had not occurred.]

Summary:

An optometrist may practice optometry in any health facility or residential facility provided that certain conditions are met, including: (1) the optometrist has a primary business office (separate from the facility) that is available by telephone during normal business hours for access to patient records; (2) the optometrist complies with all state and federal laws regulations regarding maintenance and protection of health records; (3) records are maintained so that the type and extent of services provided to patients are conspicuously disclosed; (4) the records are disclosed to patients at or near the time of services rendered and are maintained in a designated office; (5) information about prescriptions issued to a patient are included in the patient's chart; (6) a copy of any referral or order requesting optometric services for a patient from the health facility's or residential care facility's administrator, director of social services, the attending physician and surgeon, the patient, or a family member shall be kept in the patient's medical record; and (7) the optometrist keeps all necessary records for a minimum of seven years from the date of service in order to disclose fully the extent of services furnished to a patient.

Summary:

A medical assistant may only administer medication in certain ways, and only with "specific authorization" of a licensed physician that is placed in the patient's medical record.

Summary:

If a physician or surgeon conducts a scheduled medical procedure outside a general acute care hospital resulting in the patient's transfer to an emergency center, he must complete a form with specified information that is then placed in the patient's medical record.

Summary:

A physician who removes sperm or ova from a patient shall obtain written consent and retain such in the patient's medical record.

Summary:

If the licensed midwife does not have liability coverage for the practice of midwifery, the midwife and client shall sign a disclosure statement of this fact, to be included in the client's medical record.

Summary:

Any health limitation that requires a contact lens prescription to be less than one year shall be documented in the patient's medical record.

Summary:

Occupational therapists are required to document evaluation, goals, treatment plan and summary of treatment in the patient record. These records shall be maintained for a minimum of seven years following patient's discharge, except records of a minor shall be maintained at least until one year after the minor.

Summary:

In any case where it is required that an optometrist consult with an ophthalmologist, the optometrist shall maintain a written record in the patient's file of the information provided to the ophthalmologist, the ophthalmologist's response, and any other relevant information. Upon the consulting ophthalmologist's request and with the patient's consent, the optometrist shall furnish a copy of the record to the ophthalmologist.

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