Section 946.320  Records Maintained by the Health Care Professional and Department

A health care professional certifying the use of medical cannabis by a qualifying patient shall establish a medical record for the qualifying patient with regard to the patient's medical condition and continued treatment for the condition or conditions under the health care professional's care.  The certifying health care professional shall maintain a record-keeping system for all patients for whom the certifying health care professional has recommended the use of medical cannabis.  These records shall be accessible to and subject to review by the Departments of Public Health and Financial and Professional Regulation upon request. (Section 35 of the Act) These records do not need to be maintained separately from the established records the certifying health care professional maintains on the patient during the course of the ongoing bona-fide health care professional-patient relationship.

a)         In addition to records required to be maintained pursuant to the applicable federal and State statutes and all applicable rules, the records shall accurately reflect the evaluation and treatment of the qualifying patient, and shall include the following as applicable:

1)         The patient's name and the date or dates of visits and treatment;

2)         The patient's medical history and updated health history;

3)         Documented results of a full assessment of the patient's medical history, including review of medical records from other treating health care professionals from the previous 12 months;

4)         A description of the patient's current medical condition;

5)         Documented results of the certifying health care professional's physical examination of the patient;

6)         A treatment plan;

7)         General consent for treatment;

8)         Diagnosis and treatment rendered;

9)         A list of the drugs prescribed, administered and dispensed, and the quantity of the drugs;

10)         Radiographs and diagnostic tests;

11)         Patient financial and billing records;

12)         The name of the certifying health care professional and any assistive personnel providing services; and

13)         Laboratory results.

b)         The records for each qualifying patient for whom the health care professional has certified medical cannabis usage shall be kept for a minimum of three years after the certifying health care professional last sees the patient.

c)         The Department will maintain a confidential record of each certifying health care professional for the purpose of monitoring compliance with the Act.  This confidential record will not be subject to requests under the Freedom of Information Act.

(Source:  Amended at 45 Ill. Reg. 6205, effective April 27, 2021)