Responsibilities relating to provider performance - 55 Pa. Code § 1102.34

The operator of a shared health facility must insure that providers rendering services to recipients at the facility and persons employed by the facility do the following:

• Only refer a recipient to a provider when there is medical justification for the referral that is clearly set forth in the medical records of the referring practitioner;
• Communicate in writing to any referring practitioner the diagnostic evaluation and therapy rendered, and incorporate this information into the recipient’s records.

Maintain proper recipient records for at least four years which contain the following information:

• The recipient’s full name, address and medical assistance number;
• The dates of visits by a recipient and whether he was instructed to return for further treatment;
• The major complaint and diagnostic impressions for each visit;
• Pertinent history and physical examinations rendered by each provider;
• A listing of medications prescribed and the precise dosage and prescription regimens for each;
• Orders for X-rays, laboratory work and diagnostic tests and the results of such tests;
• The medical documentation justifying the necessity of diagnostic procedures ordered by a practitioner, regardless of who performs the procedure; and
• Referrals by practitioners to other providers and the reasons for the referrals.