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2 | 2 | | FIRST REGULAR SESSION |
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3 | 3 | | SENATE BILL NO. 261 |
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4 | 4 | | 103RD GENERAL ASSEMBLY |
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5 | 5 | | INTRODUCED BY SENATOR MOSLEY. |
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6 | 6 | | 0066S.01I KRISTINA MARTIN, Secretary |
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7 | 7 | | AN ACT |
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8 | 8 | | To repeal section 334.097, RSMo, and to enact in lieu thereof one new section relating to patient |
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9 | 9 | | records. |
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10 | 10 | | |
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11 | 11 | | Be it enacted by the General Assembly of the State of Missouri, as follows: |
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12 | 12 | | Section A. Section 334.097, RSMo, is repealed and one new 1 |
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13 | 13 | | section enacted in lieu thereof, to be known as section 334.097, 2 |
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14 | 14 | | to read as follows:3 |
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15 | 15 | | 334.097. 1. Physicians shall maintain an adequate and 1 |
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16 | 16 | | complete patient record for each patient and may maintain 2 |
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17 | 17 | | electronic records provided the record -keeping format is 3 |
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18 | 18 | | capable of being printed for review by the state board of 4 |
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19 | 19 | | registration for the healing arts. An adequate and complete 5 |
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20 | 20 | | patient record shall include documentation of the following 6 |
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21 | 21 | | information: 7 |
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22 | 22 | | (1) Identification of the patient, includi ng name, 8 |
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23 | 23 | | birthdate, address and telephone number; 9 |
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24 | 24 | | (2) The date or dates the patient was seen; 10 |
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25 | 25 | | (3) The current status of the patient, including the 11 |
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26 | 26 | | reason for the visit; 12 |
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27 | 27 | | (4) Observation of pertinent physical findings; 13 |
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28 | 28 | | (5) Assessment and clinical impression of diagnosis; 14 |
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29 | 29 | | (6) Plan for care and treatment, or additional 15 |
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30 | 30 | | consultations or diagnostic testing, if necessary. If 16 |
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31 | 31 | | treatment includes medication, the physician shall include 17 SB 261 2 |
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32 | 32 | | in the patient record the medication and dosag e of any 18 |
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33 | 33 | | medication prescribed, dispensed or administered; 19 |
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34 | 34 | | (7) Any informed consent for office procedures ; and 20 |
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35 | 35 | | (8) If requested to be documented by the patient, any 21 |
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36 | 36 | | question asked related to the care and treatment of the 22 |
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37 | 37 | | patient and the phys ician's response to such question . 23 |
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38 | 38 | | 2. Patient records remaining under the care, custody 24 |
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39 | 39 | | and control of the licensee shall be maintained by the 25 |
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40 | 40 | | licensee of the board, or the licensee's designee, for a 26 |
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41 | 41 | | minimum of seven years from the date of when th e last 27 |
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42 | 42 | | professional service was provided. 28 |
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43 | 43 | | 3. Any correction, addition or change in any patient 29 |
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44 | 44 | | record made more than forty -eight hours after the final 30 |
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45 | 45 | | entry is entered in the record and signed by the physician 31 |
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46 | 46 | | shall be clearly marked and identifi ed as such, and the 32 |
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47 | 47 | | date, time and name of the person making the correction, 33 |
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48 | 48 | | addition or change shall be included, as well as the reason 34 |
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49 | 49 | | for the correction, addition or change. 35 |
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50 | 50 | | 4. A consultative report shall be considered an 36 |
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51 | 51 | | adequate medical reco rd for a radiologist, pathologist or a 37 |
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52 | 52 | | consulting physician. 38 |
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53 | 53 | | 5. The board shall not initiate disciplinary action 39 |
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54 | 54 | | pursuant to subsection 2 of section 334.100 against a 40 |
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55 | 55 | | licensee solely based on a violation of this section. If 41 |
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56 | 56 | | the board initiates d isciplinary action against the licensee 42 |
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57 | 57 | | for any reason other than a violation of this section, the 43 |
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58 | 58 | | board may allege violation of this section as an additional 44 |
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59 | 59 | | cause for discipline pursuant to subdivision (6) of 45 |
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60 | 60 | | subsection 2 of section 334.100. 46 |
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61 | 61 | | 6. The board shall not obtain a patient medical record 47 |
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62 | 62 | | without written authorization from the patient to obtain the 48 SB 261 3 |
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63 | 63 | | medical record or the issuance of a subpoena for the patient 49 |
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64 | 64 | | medical record. 50 |
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65 | 65 | | |
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