21 NCAC 64 .0209             ADEQUACY OF RECORDS

(a)  The definition of "adequate records of professional services" required to be maintained by Rule .0303(4) shall include:

(1)           The full name of the patient;

(2)           The nature of the service provided;

(3)           The date services were provided;

(4)           The identification of the person providing the service;

(5)           The identification of the person preparing or signing the record if not by the person providing the service.

(b)  Corrections shall be made by drawing a single line through the error without obliterating the error and shall be initialed by the person making the correction.

(c)  Records of professional services rendered shall be maintained for a minimum period of three years.

History Note:        Authority G.S. 90-304(a)(3).

Eff. July 1, 1998;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. October 4, 2016.