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COMAR 10.07.05.14 — Clinical Records
MarylandregulationMaryland Department of Health, Office of Health Care Quality
What this rule requires your agency to do
- 1Maintain a clinical record for each client in a manner ensuring security and confidentiality, including at minimum the care notes required by §D, currently effective health care orders, nurse's assessment, rehabilitation plans if appropriate, the care plan, medications (dosage, route, frequency), sensitivities/allergies, nutritional requirements, medically necessary supplies/equipment, care notes, and physician/representative contact information (§A).(COMAR 10.07.05.14 — Clinical Records)
- 2For clients assessed as not requiring certified caregivers or skilled services, maintain a client record including nursing assessment, plan of care, services provided, any significant change of condition, and other pertinent information (§B).(COMAR 10.07.05.14 — Clinical Records)
- 3Ensure all notes and reports in the clinical record (including electronic records) are detailed, legible, chronological, dated, and signed with the name and title of the individual rendering the service (§D(2)).(COMAR 10.07.05.14 — Clinical Records)
- 4Develop policies and procedures ensuring information about a client's condition or preferences (including any significant change of condition) is documented and communicated in a timely manner to the client, the client representative if appropriate, and all appropriate health care professionals and staff involved in the care plan (§C).(COMAR 10.07.05.14 — Clinical Records)
- 5Ensure appropriate staff write care notes at minimum on admission and at least weekly, upon any significant change in condition, and when the care plan is modified (§D(1)).(COMAR 10.07.05.14 — Clinical Records)
- 6Include in each clinical record upon discharge directions for safe continuation of care, and, if skilled services were provided, a discharge summary stating the reason for discharge (§A(12)).(COMAR 10.07.05.14 — Clinical Records)
Applies to: personal care
Specifies the required contents of each client's clinical record (health care orders, nurse's assessment, care plan, medications, allergies, nutrition, supplies, care notes, contacts, discharge documents), a reduced record for clients not requiring certified caregivers or skilled services, documentation and communication of changes of condition, and care-note frequency and legibility standards. Framework topic: Clinical Records & Documentation.
Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.