Sec. 14.09.08.07. Medical Records

A. Medical records are the basis for determining whether a particular treatment or service is medically necessary and, therefore, reimbursable.

B. Each health care provider is responsible for creating and maintaining legible medical records documenting the employee's course of treatment.

C. Employee medical records shall include the:

(1) History of the patient;

(2) Results of a physical examination performed in conformity with the standard of practice of similar health care providers, with similar training, in the same or similar communities;

(3) Progress, clinical, or office notes that reflect:

(a) Subjective patient complaints;

(b) Objective findings of the provider;

(c) Assessment of the presenting problem;

(d) Any plan or plans of care or recommendations for treatment; and

(e) Updated assessments of patient's medical status and response to therapy;

(4) Copies of lab, x-ray, or other diagnostic tests, if any, that reflect the current progress of the patient and response to therapy; and

(5) Hospital inpatient and outpatient records, if any, including:

(a) Operation reports;

(b) Test results;

(c) Consultation reports;

(d) Discharge summaries; and

(e) Other dictated reports.

D. Writing, Maintaining, and Submitting Medical Records.

(1) Employee medical records shall be submitted to the employer or insurer, or, upon request, to the Commission.

(2) The cost of maintaining medical records is included in the treatment and service fees established by the Official Maryland Workers' Compensation Medical Fee Guide (1995) and this chapter. A provider may not submit a separate fee for writing or maintaining medical records.

(3) Additional Medical Report Fees.

(a) Upon the request of any party or the Commission, a provider shall promptly write and submit the requested additional medical reports.

(b) When additional medical reports are requested by the Commission, a provider may not charge a fee for writing or preparing the additional medical reports.

(c) When additional medical reports are requested by any party, the provider may seek reimbursement under Regulation .06 of this chapter.

(4) Copies of Medical Records and Additional Medical Reports.

(a) Requests for Copies of Medical Records.

(i) A party requesting medical records shall ensure that the request is reasonable and specific.

(ii) Health care providers shall respond promptly to requests for medical records and additional medical reports.

(iii) Health care providers may request clarification regarding which medical records and medical reports are the subject of the request.

(iv) Copies of medical records that were not specifically requested by the payor, are not subject to reimbursement under this chapter.

(b) Fees for Copying.

(i) When requested by the injured employee, injured employee's attorney, the employer, or insurer, copies of medical records and additional medical reports will be reimbursed pursuant to Health-General Article, §4-304(c), Annotated Code of Maryland, and other applicable law.

(ii) Medical record requests by the Commission will be furnished by the provider without charge.