Medical record documentation requirements

(a) The attending physician shall document and file in the medical record of the patient requesting a covered medication: (1) All oral requests by a patient for a covered medication; (2) All written requests by a patient for a covered medication; (3) The attending physician's: (A) Diagnosis and prognosis of the patient; (B) Determination that the patient is a District resident and is capable, acting voluntarily, and has made an informed decision when requesting a covered medication; (C) Offer to the patient to rescind his or her request for a covered medication before the patient makes his or her second oral request; (D) Notation that all requirements under this chapter have been met; and (E) Notation regarding all steps taken to carry out the patient's request for a covered medication, including a notation of the covered medication prescribed; (4) The consulting physician's: (A) Diagnosis and prognosis of the patient; (B) Verification that the patient is capable, acting voluntarily, and has made an informed decision when requesting a covered medication; and (5) If a patient is referred to counseling pursuant to § 7-661.04, a report by the psychiatrist or psychologist of the outcome and determinations made during counseling.