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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

Subtopic Statute/Regulation Description
Right to access to medical records (Access by representative or other person authorized by the patient through informed consent; copying fees, or other requirements (e.g., requirement to give patient access in electronic format)) Hospital Medical Staff Access to Records – Ind. Code Ann.§ 16-39-6-1 Hospital Medical Staff Access to Records The state of Indiana finds it in the public interest to give hospital medical staff committees access to...
Persons Entitled to Request Records – Ind. Code Ann.§ 16-39-1-3 Health care records may be requested by a competent patient if he or she is at least 18 years old (or younger than 18 but emancipated).  If a...
Practitioners Required to Create and Maintain a Health Record – Ind. Code Ann.§ 16-39-7-1 Health care providers must maintain the original health records or microfilms of the records for at least 7 years.  Providers who violate this...
Required Fees to be Charged for Producing Medical Record Copies – 760 Ind. Admin. Code 1-71-3 A provider or a medical record company that receives a request for a patient’s medical record must adhere to the following charges for...
Requirements for a Provider's Use of Records and Violations of Use of Records – Ind. Code Ann.§ 16-39-5-3 The law provides that a patient’s health record is the property of the provider, and may be used by the provider for legitimate business...
Requirements for Ability to Make Health Care Decisions – Ind. Code Ann.§ 16-36-1-4 An individual may consent to health care or treatment unless the health care provider finds that the person is incapable of making a health care...
Requirements for Access to a Child's Health Care Record by Custodial and Noncustodial Parents – Ind. Code Ann.§ 16-39-1-7 Access to a Child's Health Care Record by Custodial and Noncustodial Parents A custodial parent, and a noncustodial parent of a child have equal...
Requirements for Access to Autopsy Records by Surviving Family, Government Entities and Other Providers – Ind. Code Ann.§ 16-39-7.1-3 A surviving spouse may view and copy photographs, video recordings, or audio recordings of the deceased spouse’s autopsy.  If there is no...
Requirements for Adequate Medical Records in Ambulatory Centers – 410 Ind. Admin. Code 15-2.5-3 An adequate medical record must be maintained for each patient of the center.  All medical records must be maintained by the center for seven...
Requirements for Consent to Health Care and Exceptions – Ind. Code Ann.§ 16-36-1-3 The following individuals may consent to their own care, unless they fall within the exceptions under Ind. Code § 16-36-1-4: An adult; An...
Requirements for Disclosure of Medical Information to Individuals Authorized to Consent – Ind. Code Ann.§ 16-36-1-11 A person who is authorized to consent for another individual has the same rights of receiving health care information and consenting to the release...
Requirements for Maintenance and Availability of X-Rays by Providers – Ind. Code Ann.§ 16-39-7-2 Providers must maintain a patient’s x-ray film for at least 5 years.  At the time the x-ray is taken, the provider must either inform the...
Requirements for Medical Record Maintenance and Administration in Hospitals – 410 Ind. Admin. Code 15-1.5-4 The medical record services has administrative responsibility for the medical records that are maintained for every individual evaluated or treated...
Requirements for Medical Record Maintenance in Interactive Internet Medical Practice Sites – 844 Ind. Admin. Code 5-3-7 Interactive internet medical practice sites are practice locations, and must clearly disclose to patients the following: ·   ...
Requirements for Patient’s Written Consent to Insurer to Obtain Records or Medical Information – Ind. Code Ann.§ 16-39-5-2 An accident and sickness insurance company may obtain health records or medical information about a patient with a written consent executed at the...
Requirements for Provision of a Mechanism to Amend, Access or Supplement Patient-Provided Personal Health Information by Medical Practice Sites – 844 Ind. Admin. Code 5-3-8 All medical practice sites must provide patients a clear mechanism to access, supplement, and amend patient-provided personal health information;...
Requirements for Requests for Medical Records by Hospital Inpatients – Ind. Code Ann.§ 16-39-1-6 An individual who is currently an inpatient in a hospital or health facility is not authorized to obtain a copy of his or her health records while...
Requirements for Withholding Requested Medical Record Information – Ind. Code Ann.§ 16-39-1-5 If a provider reasonably decides that a request for medical records will be detrimental to the physical or mental health of the patient, or is likely...
Medical Records Collection, Retention, and Access Case Withdrawal - 844 Ind. Admin. Code 5-2-4 Case Withdrawal No practitioner shall abandon a patient. In the event a practitioner must withdraw from a case, he or she shall give reasonable...
Ind. Code Ann. § 16-39-2-2 - Maintenace of records by providers of mental health services This law requires that a provider maintain a record for each patient receiving mental health services, and that the record contain all the...
Ind. Code Ann. § 16-39-2-4 - Patient access to mental health records This law states that patients are entitled to inspect and copy their own records unless the provider who maintains the records determines, with a...
Ind. Code Ann. § 16-39-2-5 - Access to mental health records by patient’s designee or legal representative This law allows private and public mental health care providers to give access to a patient’s mental health record to an individual or...
Ind. Code Ann. § 16-39-4-2 - "Primary caregiver"; written request from relative or guardian for information; provision of mental health records to a school This law allows a provider to give access to a patient’s mental health records to a patient’s spouse/parent/adult child/sibling/guardian...
Ind. Code Ann. § 16-41-6-9 - Information on confidential part of birth certificate This law states that the state department of health requires that every birth/stillbirth certificate’s confidential portion retained by the...
Ind. Code Ann. § 27-13-31-4 - Access to records by HMO to run a quality management program This law allows an HMO to access treatment records related to the diagnosis, treatment and health status of any enrollee during the time that the...
Informed Consent – 844 Ind. Admin. Code 5-3-5 A written agreement must be used that documents the patient’s informed consent for the use of patient-physician email.  The agreement must...
Inter-Provider Exchange of Records Without Patient’s Consent – Ind. Code Ann.§ 16-39-5-1 Providers are allowed to obtain a patient’s health records from another provider without the patient’s consent if the health records are...
Requirements for Access, Maintenance, and Requests for Health Records (Excluding Records for Mental Health, Communicable Diseases, and Drug and Alcohol Abuse) – Ind. Code Ann. § 16-39-1-1 This section applies to all health records except mental health records, records regarding communicable diseases, and records pertaining to drug and...
Controlled substances records Confidentiality and Disclosure Requirements for Alcohol and Drug Abuse Records – Ind. Code Ann. § 16-39-1-9 All substance abuse treatment records are confidential and may only be disclosed as permitted by Part 2.
Other Confidentiality and Disclosure Requirements for Alcohol and Drug Abuse Records – Ind. Code Ann. § 16-39-1-9 All substance abuse treatment records are confidential and may only be disclosed as permitted by Part 2.
Destruction, storage and filing of medical records (Cross reference with Security of Health Information) Hospital Requirements for Addressing Unusual Occurrences or Disasters – 410 Ind. Admin. Code 15-1.2-1 A hospital must have plans to address the review and reporting of unusual occurrences and disasters.  Unusual occurrences or disasters include...
Practitioners Required to Create and Maintain a Health Record – Ind. Code Ann.§ 16-39-7-1 Health care providers must maintain the original health records or microfilms of the records for at least 7 years.  Providers who violate this...
Requirements for Maintenance and Availability of X-Rays by Providers – Ind. Code Ann.§ 16-39-7-2 Providers must maintain a patient’s x-ray film for at least 5 years.  At the time the x-ray is taken, the provider must either inform the...
Requirements for Maintenance and Confidentiality of Records of Proceedings for Health Maintenance Organizations – Ind. Code Ann.§ 27-13-6-8 A health maintenance organization (HMO) record all proceedings related to quality management activities and maintain the confidentiality of those...
Requirements for Maintenance of Original Mammogram Films by Providers – Ind. Code Ann.§ 16-39-7-3 Providers must maintain a patient’s original mammogram films and reports in a permanent medical record of the patient for not less than 5years...
Retention periods Practitioners Required to Create and Maintain a Health Record – Ind. Code Ann.§ 16-39-7-1 Health care providers must maintain the original health records or microfilms of the records for at least 7 years.  Providers who violate this...
Requirements for Adequate Medical Records in Ambulatory Centers – 410 Ind. Admin. Code 15-2.5-3 An adequate medical record must be maintained for each patient of the center.  All medical records must be maintained by the center for seven...
Requirements for Maintenance and Availability of X-Rays by Providers – Ind. Code Ann.§ 16-39-7-2 Providers must maintain a patient’s x-ray film for at least 5 years.  At the time the x-ray is taken, the provider must either inform the...
Requirements for Maintenance of Original Mammogram Films by Providers – Ind. Code Ann.§ 16-39-7-3 Providers must maintain a patient’s original mammogram films and reports in a permanent medical record of the patient for not less than 5years...
Requirements for Medical Record Maintenance and Administration in Hospitals – 410 Ind. Admin. Code 15-1.5-4 The medical record services has administrative responsibility for the medical records that are maintained for every individual evaluated or treated...
Requirements for the Establishment and Maintenance of Medical Records Under Medicaid – 405 Ind. Admin. Code 1-5-1 All Medicaid participating providers must maintain records of services provided under the Medicaid program for seven years.  The records must...
Content of medical record Requirement to Include Electronic Communications in Patient Medical Records – 844 Ind. Admin. Code 5-3-6 The medical record must include written or electronic copies of all patient related electronic communications, including: Patient-physician email...
Requirements for Access to Autopsy Records by Surviving Family, Government Entities and Other Providers – Ind. Code Ann.§ 16-39-7.1-3 A surviving spouse may view and copy photographs, video recordings, or audio recordings of the deceased spouse’s autopsy.  If there is no...
Requirements for Adequate Medical Records in Ambulatory Centers – 410 Ind. Admin. Code 15-2.5-3 An adequate medical record must be maintained for each patient of the center.  All medical records must be maintained by the center for seven...
Requirements for Certificates of Birth – Ind. Code Ann. § 16-37-2 A licensed physician, a midwife or a nurse midwife in attendance at a live birth shall file with the local health officer a certificate of birth and...
Requirements for Certificates of Death and Stillbirth – Ind. Code Ann. § 16-37-3 The individual in charge of interment of a stillborn child or dead body must file a certificate of death or of stillborn with the local health...
Requirements for Medical Record Maintenance and Administration in Hospitals – 410 Ind. Admin. Code 15-1.5-4 The medical record services has administrative responsibility for the medical records that are maintained for every individual evaluated or treated...
Requirements for the Establishment and Maintenance of Medical Records Under Medicaid – 405 Ind. Admin. Code 1-5-1 All Medicaid participating providers must maintain records of services provided under the Medicaid program for seven years.  The records must...
Required maintenance of medical records Requirements for Adequate Medical Records in Ambulatory Centers – 410 Ind. Admin. Code 15-2.5-3 An adequate medical record must be maintained for each patient of the center.  All medical records must be maintained by the center for seven...
Requirements for Medical Record Maintenance and Administration in Hospitals – 410 Ind. Admin. Code 15-1.5-4 The medical record services has administrative responsibility for the medical records that are maintained for every individual evaluated or treated...
Requirements for the Establishment and Maintenance of Clinical Records in Comprehensive Care Facilities – 410 Ind. Admin. Code 16.2-3.1-50 Comprehensive Care Facilities must maintain clinical records on each resident.  These records must be maintained under the supervision of an...
Requirements for the Establishment and Utilization of Patient Record Systems by Health Maintenance Organizations – Ind. Code Ann.§ 27-13-6-6 A health maintenance organization (HMO) must use a patient record system that allows for retrieval of patient records easily in order to evaluate the...