030-11 Wyo. Code R. §§ 11-4 - Patient Records

(a) Basic Requirements.

(i) Records include any medical decision making documents, whether hard copy or digital.

(ii) Each patient record shall, at a minimum, include legible documentation of the following:

(A) The patient's identifying information and identity of the treating licensee and all health care providers;

(B) The reason for the clinical encounter, including any subjective complaints and pertinent history;

(C) The current objective findings and results of diagnostic studies;

(D) The diagnosis and assessment of the patient's condition;

(E) A management and care plan, including the recommendations, intended goals, prognosis, modifications to the plan, and the procedures provided;

(F) Evidence of informed consent.

(G) Radiographs shall include the patient's first name, last name, date of birth, date of study, and location of study. It is preferable to embed this information in the radiograph.

(b) Informed Consent.

(i) Licensees shall inform the patient about the availability of reasonable alternate modes of treatment and about the benefits and risks of these treatments. The reasonable chiropractor standard is the standard for informing a patient. The reasonable chiropractor standard requires disclosure only of information that a reasonable chiropractor would know and disclose under the circumstances.

(ii) Initial written consent shall be obtained prior to performing procedures.

(iii) Treatment of minors requires the informed consent of a legal guardian, unless the minor may consent to treatment pursuant to W.S. 14-1-101(b).

(iv) Licensees have an obligation to evaluate patient capacity to comprehend consent and make a choice regarding whether informed consent was obtained. Capacity means an individual's ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision.

(c) Records Retention.

(i) Licensees shall not withhold records or diagnostic studies if a patient owes an outstanding balance.

(ii) Patient records and diagnostic studies shall be:

(A) Maintained for a minimum of seven (7) years from the date of the last patient clinical encounter;

(B) Maintained in a physically secure and confidential manner; and

(C) Accessible to the patient and treating doctor within a reasonable period.

(d) Violation of any provision above shall be considered "unprofessional conduct" within the meaning of Chapter 7 and shall constitute grounds for disciplinary action by the Board.

Notes

030-11 Wyo. Code R. §§ 11-4

Adopted, Eff. 3/29/2018. Amended, Eff. 7/5/2023.