Requirements for Maintenance of Patient Records by Physicians - Mo. Rev. Stat. §334.097

Physicians must maintain adequate records on each patient for at least seven years from the date of last service performed.  The records may also be maintained in electronic format.  Any corrections, modifications or deletions made in the patient record must be clearly outlined in the patient record.  The patient record must contain the following information:

• Patient’s name, address, birth date and phone number;
• Date the patient was seen;
• Current status of the patient, including reason for visit;
• Physical findings;
• Diagnosis;
• Treatment plan, including medications;
• Informed consent;

The medical board may not pursue disciplinary action against a physician solely based on violation of this section.  If other violations are alleged, violation of this section may be included.  In conducting an investigation, the medical board must obtain the written authorization of the patient to receive the patient’s record.