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Medical records - 49 Pa. Code § 16.95

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Physicians must maintain medical records for patients that accurately and completely reflect the evaluation and treatment of the patient and clearly identify the patient and his complaints and symptoms.  Clinical information pertaining to the patient must be incorporated into the medical record, including diagnoses, the findings and results of pathologic or clinical laboratory examination, radiology examination, medical and surgical treatment and other diagnostic, corrective or therapeutic procedures.  Patients’ medical records must be retained for at least seven years after the date of the last medical service; medical records of minor patients must be retained for one year after majority.

Current as of June 2015