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Medical Records Collection, Retention, and Access in Indiana

Indiana law requires all health care providers to maintain patients’ original health records or microfilms of the records for at least seven years, or be subject to disciplinary sanctions.  Providers who are subject to this regulation include physicians, hospitals, nurses, and other health care professionals specified in the regulation.1  Indiana law also takes into account electronic communications, and requires that patient medical records include written or electronic copies of all patient related electronic communications.2

 

            Although the state has a general law requiring health care providers to maintain medical records, there is also a separate law pertaining to hospitals’ medical records obligations.  Hospitals are required to keep records for each individual who is evaluated or treated.  The records must be accurate, timely, and be readily accessible.  The law requires that medical records contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and accurately document the course of treatment and results.3  There is a separate statute that requires that ambulatory care centers maintain adequate medical records for each patient of the center.4  Similarly, Indiana requires Comprehensive Care Facilities to maintain clinical records on each resident.  The law requires that clinical records be kept after discharge for a minimum of one year in the facility and five years total for adults, or until the patient reaches the age of 21 for minors.  The facility must also safeguard clinical record information against loss, destruction or unauthorized use.  Clinical records must contain sufficient information to identify the patient, a record of the resident’s assessments, the care plan and services provided, the results of any preadmission screening conducted by the state, and all progress notes.5

 

            Providers who participate in the Medicaid program are subject to additional requirements under Indiana law.  Medicaid participating providers must maintain medical records for a period of at least seven years, and must fully describe the scope and extent of treatment provided.  There are specific elements that the Medicaid medical record must contain, separate and apart from the general requirements of all medical records.6

 

            The state of Indiana also has specific laws that give patients the right to access their health records possessed by a health care provider upon written request and for a fee.7  Competent adults or emancipated minors may request their own health care records, and guardians, spouses, or personal representatives may request health care records of minors, incompetent individuals, or the deceased.8  Health care providers must provide access to the health records as long as the provider determines that access to a patient’s health care records will not be detrimental to his or her physical or mental health.9  The state does provide an exception to the access rule by prohibiting hospital inpatients from gaining access to their health records during the time they are in the hospital.  However, the law provides that health records can be released to the hospital inpatient’s spouse, guardian or next of kin.10  In addition, Indiana requires that all medical practice sites give patients the right to amend, modify or supplement personal health information.11

 

 

 

Footnotes

  • 1. Ind. Code §16-39-7-1
  • 2. 844 Ind. Admin. Code 5-3-6
  • 3. 410 Ind. Admin. Code 15-1.5-4
  • 4. 410 Ind. Admin. Code 15-2.5-3
  • 5. 410 Ind. Admin. Code 16.2-3.1-50
  • 6. 405 Ind. Admin Code 1-5-1
  • 7. Ind. Code §16-39-1-1; 760 Ind. Admin. Code 1-71-3
  • 8. Ind. Code §16-39-1-3
  • 9. Ind. Code §16-39-1-5
  • 10. Ind. Code §16-39-1-65
  • 11. 844 Ind. Admin. Code 5-3-8

 

Medical Records Collection, Retention, and Access in Indiana

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