55 Pa. Code § 1101.51
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Ongoing responsibilities of providers
Recipients of medical assistance may obtain services from any institution, agency, pharmacy, person or organization that is approved by the department of welfare to provide such services. Providers are prohibited from denying services or otherwise discriminating against a medical assistance recipient on the grounds of race, color, national origin or handicap.
Every practitioner providing medical care to medical assistance recipients is required to adhere to basic standards of practice, which includes maintenance of a proper record for each patient that contains the following information:
- A complete medical history of the patient;
- The patient’s complaints accompanied by the findings of a physical examination;
- A preliminary working diagnosis as well as a final diagnosis and the elements of a history and physical examination upon which the diagnosis is based;
- Treatments as well as the treatment plan;
- Drugs prescribed as part of the treatment, including the quantities and dosages;
- Summaries of hospitalizations and reports of operative procedures and excised tissues;
- The results, including interpretations of diagnostic tests and reports of consultations;
- The disposition of the case; and
- Documentation of the medical necessity of a rendered, ordered or prescribed service.
Providers must retain fiscal records relating to services they have rendered to medical assistance recipients.!doctype>