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Medical Records - CRIR 14-090-007, § 27.12
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Current as of June 2015
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Medical Records
A medical record must be created and maintained for every person treated on an inpatient, outpatient (ambulatory) or emergency basis, in any unit of the hospital, and such record must be available to all other units. Written policies and procedures must be established regarding content and completion of medical records by an appropriate multidisciplinary group, which will also be responsible for ongoing review. Entries in the medical record must be made by the responsible person in accordance with hospital policies and procedures. The medical record should contain sufficient information to identify the patient and the problem, to describe the treatment, and to document the results of the treatment. Medical records must document the primary language of the patient, any hospital provision of interpretive services, and any inability to provide interpretive services as required by the patient.
The medical record, including the discharge summary, must be completed within 30 days of the patient's discharge. Provisions must be made for the safe storage of medical records, which must be maintained for at least 5 years after a patient is discharged, or in the case of a minor patient, at least until the minor is 23 years old. A mechanism must be established to ensure confidentiality of all medical records, including computerized or electronic records.
Patient Access to Medical Records
Medical records are considered the property of the hospital, but may be requested in writing by the patient or an authorized representative. Within 30 days of receipt of such request, or within 30 days of completion of the record (whichever is later), the hospital must provide the requested record. The hospital may not charge a fee for a record if it is requested for continuity of care purposes, for immunization records required for school admissions, or for purposes of supporting a claim or appeal under the provision of the Social Security Act or any federal or state needs-based benefit program. The hospital may not charge a fee to an applicant for benefits in connection with a Civil Court Certification Proceeding or a claim under the Worker’s Compensation Act. Medical records that are not claimed within 5 years of the last date of discharge may be destroyed, provided that certain requirements are met.
Hospital Closure/Change in Ownership and Medical Records
A hospital must notify the public if it is voluntarily closing, or if there is a change in ownership, via a multimedia press release sent out within 30 days of the closure/change of ownership, which includes the procedure by which individuals may obtain their medical records. If a hospital changes ownership, all medical records in original, electronic, or microfilm form must remain in the hospital or related institution, become part of the ownership agreement, and the new owner will be responsible for protecting and maintaining these records. If any hospital closes permanently, its medical records may be delivered to any other hospital(s) in the vicinity willing to accept and retain them, or may be delivered to any other lawfully permitted agency. Patients or their representatives must be provided with an opportunity to claim their records prior to destruction of the records in the event of closure or change in ownership of the hospital.
Current as of June 2015
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