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Medical records - 49 Pa. Code § 25.213

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Every osteopathic physician must maintain a medical record for each patient that identifies the patient and provides pertinent clinical information, diagnoses, findings, laboratory results and other diagnostic, corrective or therapeutic procedures.  Medical records must be retained for at least seven years from the date of the last entry; minors’ medical records must be retained for two years after majority, or seven years from the last entry, whichever is later.  Physicians must provide a patient with a complete copy of his medical records within a reasonable time of a request for a copy from the patient or an authorized representative, and may charge a reasonable copying fee.  Medical records must be kept confidential, but may be disclosed in the following circumstances:

  • When disclosure is required for bona fide treatment, with the patient's written consent;
  • Upon receipt of a court order;
  • Upon lawful demand by auditors for public or private payers that have contracted to reimburse the physician for services provided to the patient;
  • To defend against allegations of civil or criminal medical malpractice in certain circumstances; and
  • To comply with other relevant state and federal health care laws.

Current as of June 2015