A health care professional certifying the use of medical
cannabis by a qualifying patient shall establish a medical record for the
qualifying patient with regard to the patient's medical condition and continued
treatment for the condition or conditions under the health care professional's
care. The certifying health care professional shall maintain a
record-keeping system for all patients for whom the certifying health care
professional has recommended the use of medical cannabis. These records shall
be accessible to and subject to review by the Departments of Public Health and
Financial and Professional Regulation upon request. (Section 35 of the
Act) These records do not need to be maintained separately from the established
records the certifying health care professional maintains on the patient during
the course of the ongoing bona-fide health care professional-patient
relationship.
a) In addition to
records required to be maintained pursuant to the applicable federal and State
statutes and all applicable rules, the records shall accurately reflect the
evaluation and treatment of the qualifying patient, and shall include the
following as applicable:
1) The patient's name
and the date or dates of visits and treatment;
2) The patient's medical history and updated
health history;
3) Documented
results of a full assessment of the patient's medical history, including review
of medical records from other treating health care professionals from the
previous 12 months;
4) A
description of the patient's current medical condition;
5) Documented results of the certifying
health care professional's physical examination of the patient;
6) A treatment plan;
7) General consent for treatment;
8) Diagnosis and treatment
rendered;
9) A list of the drugs
prescribed, administered and dispensed, and the quantity of the
drugs;
10) Radiographs and
diagnostic tests;
11) Patient
financial and billing records;
12)
The name of the certifying health care professional and any assistive personnel
providing services; and
13)
Laboratory results.
b)
The records for each qualifying patient for whom the health care professional
has certified medical cannabis usage shall be kept for a minimum of three years
after the certifying health care professional last sees the patient.
c) The Department will maintain a
confidential record of each certifying health care professional for the purpose
of monitoring compliance with the Act. This confidential record will not be
subject to requests under the Freedom of Information Act.
