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Section A. Section 334.097, RSMo, is repealed and one new 1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