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Operation and services; primary care center under the cabinet for health and family services department for public health regulations - 902 KY. ADMIN. REGS. 20:058

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Section 3. (5)
 
Medical records are owned by the primary care center. An original record may not be removed from the premises except by court order.
 
Medical records shall remain confidential and secure in accordance with HIPAA and its implementing regulations.
 
A primary care center must maintain a medical record for each patient and retain them for 5 years after a patient’s death or discharge or, in the case of a minor, 3 years after the patient reaches adulthood, whichever is the longest.
 
Each medical record should include the following:
·         The patient’s medical history
·         Description of each visit
·         Laboratory and test findings
·         Documentation of referrals
 
Medical records are to remain confidential. Procedures must be in place to allow for transfer of records.


Current as of January 2016