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105. Mass. Code Regs. 150.013. - Clinical and Related Records

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“Clinical and Related Records”
All facilities must provide conveniently located and suitably equipped areas for the recording and storage of records.  All records must be made permanent, either typewritten or legibly written in ink (no record shall be written in pencil). All records must be complete, accurate, current, and available on the premises of the facility for inspection by the Department.
This section lists what must be maintained by record. All facilities must also maintain a separate, complete, accurate and current clinical record in the facility for each patient or resident from the time of admission to the time of discharge. This record shall contain all medical, nursing and other related data. All entries shall be dated and signed. All facilities must also employ a medical records librarian or shall designate a trained employee of the facility to be responsible for ensuring that records are properly maintained, completed and preserved. 
All clinical records of patients including those receiving outpatient services must be completed within two weeks of discharge and filed and retained for at least five years. Provisions must be made for safe keeping for at least five years of all clinical records in the event the facility discontinues operation.  All information contained in clinical records shall be treated as confidential and shall be disclosed only to authorized persons.

Current as of June 2015