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12 Va. Admin. Code § 5-410-370 - Medical Records

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Hospital medical records departments must be staffed and equipped to permit the accurate processing, checking, indexing, filing, and retrieval of all medical records. A medical record must be established and maintained for every person treated in any unit of the hospital, which must be available to all other units. 

Hospitals must maintain a separate record for each newborn infant, which includes a chart with notes of gestational history, including any pathology and information regarding complications of delivery and mother's medication during labor and delivery. 

Hospitals must establish written policies and procedures regarding content and completion of medical records. Entries in medical records may only be made by the responsible person in accordance with hospital policies and procedures. Medical records, or accurate and legible copies of such records, must be safely stored. All medical records must be maintained for at least five years after a patient is discharged, or in the case of a minor patient, until age 23, whichever is longer. Birth and death information must be maintained for 10 years. 



Current as of June 2015