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.