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Medical Records Collection, Retention, and Access in Massachusetts

Under Massachusetts law, a physician must maintain adequate records for each patient, and retain the record for at least seven years from the date of the last encounter with the patient or until the patient reaches the age of nine (if more than seven years).1  Hospitals must also keep records of the cases treated, either in handwritten, printed, typed or electronic digital media.  The hospital can destroy the records only after the retention period of 20 years has elapsed and after notifying the Department of Public Health that the records are being destroyed.  Hospitals must inform patients of the records’ termination policy. 2  Massachusetts also imposes very specific recordkeeping requirements on hospitals.  Notably, the state requires all acute care hospitals to record each patient’s primary spoken language and race/ethnicity.3

Massachusetts also sets forth requirements for the maintenance of medical records by heath clinics.  Health clinics must maintain patient medical records for 20 years after final discharge or treatment of the patient.  Medical records can be in any format, but handwritten or typed records that have been converted into an electronic format can be destroyed before the 20 year period.  When the records are destroyed, they must preserve patient confidentiality.  The clinic must give 30 days’ notice to the patient to inform him or her that the medical record will be destroyed.4  Massachusetts law also expressly states that nursing homes and community health clinics must satisfy the minimum rules of recordkeeping set forth by the Department of Health.5

Massachusetts also has regulations that deal specifically with the maintenance of medical records for MassHealth (the state’s Medicaid program).  All providers (defined as “individual, group, facility, agency, institution, organization, or business that furnishes medical services and participates in MassHealth “) must keep documentation of the services provided under MassHealth, including medical records, to disclose the extent of and medical necessity of the services provided.  Providers must also maintain patient account records, which completely document charges, indicate debits and credits, and show the amounts billed and paid.6  Providers must keep all records for at least six years from the date of medical service for which payment claims are made.7

Massachusetts law provides that physicians must provide all patients the opportunity to inspect his or her record and have a copy of the record if the patient so requests.8  This requirement also applies to all licensed health care facilities, including hospitals and nursing homes, which are required to make medical records available to a patient or his or her authorized representative for inspection and copying upon written request.9  This right to inspect and copy and the retention policy must be provided to the patient by the hospital.  However, the law authorizes the hospital to charge a reasonable copying fee to cover administrative costs.10  The hospital or clinic cannot charge a fee to a patient who requests a copy of his or her medical record for the purpose of supporting a claim or appeal under the Social Security Act or any other federal or state financial needs based assistance program.11  Massachusetts extends the right for a patient to have access to his or her personal medical information to data held by insurance companies.12  Insurers must give consumers access to medical information in the insurer’s possession.13  Massachusetts also gives patients the right to receive an itemized list of charges from hospitals upon written request.  This right is protected to strongly that the failure of a hospital to provide the itemized bill within ten days of the request leads to the dissolution of the amount owed to the hospital.14  

Under Massachusetts law, access to medical records is also permitted by local public health departments and the Department of Health in order to monitor or prevent the spread of disease.  School officials may also be granted access to a child’s immunization records held by a health care provider without the prior authorization of the parents if parents are unable to provide these records.15  Similarly, the law allows certain disease specific registries access to patient medical records for verification purposes.16

 

Footnotes

  • 1. 243 MA ADC 2.07(13)(a)-(b)
  • 2. M.G.L.A. 111 §70
  • 3. 105 MA ADC 130.1107
  • 4. 105 MA ADC 140.302
  • 5. M.G.L.A. 111 §72; 130 MA ADC 405.412
  • 6. 130 MA ADC 410.409; 130 MA ADC 433.409
  • 7. 130 MA ADC 450.205
  • 8. 243 MA ADC 2.07(13)(a)-(b)
  • 9. M.G.L.A. 111 §70E
  • 10. 105 MA ADC 130.370
  • 11. M.G.L.A. 111 §70
  • 12. M.G.L.A. 175I §8
  • 13. 105 MA ADC 128.403
  • 14. M.G.L.A. 111 §70D
  • 15. 105 MA ADC 300.191
  • 16. 105 MA ADC 301.035; 105 MA ADC 302.050

 

Medical Records Collection, Retention, and Access in Massachusetts

Subtopic Statute/Regulation Description
Content of medical record 105. Mass. Code Regs. 130.1107. - Interpreter Service - Patient and Other Records Acute care hospitals must ensure that the primary spoken language and self identified race/ethnicity of each patient in the emergency department be...
105. Mass. Code Regs. 140.202. - Reception and Office Areas “Reception and Office Areas”   Each clinic shall provide adequate space and equipment for reception and waiting areas, for...
105. Mass. Code Regs. 140.302. - Patient Records Each health clinic must keep all patient records in a centralized location.  Each patient must have his or her own record with two forms of...
105. Mass. Code Regs. 140.611. - Reports on Surgery and Anesthesia Related Complications “Reports on Surgery and Anesthesia Related Complications”   Each clinic shall record all surgery-related or anesthesia-related...
105. Mass. Code Regs. 143.012. - Patient Records “Patient Records”   Each program shall keep in one centralized location on its premises records indicating all the services rendered...
105. Mass. Code Regs. 145.520. - Physician's Orders “Physician's Orders”   Physician orders shall be legibly entered into the medical record and shall be dated and signed by the...
105. Mass. Code Regs. 145.540. - Content of Medical Record “Content of Medical Record”   This section establishes the requirements for medical records keeping.  Each medical record shall...
105. Mass. Code Regs. 150.003. - Admissions, Transfers and Discharges “Admissions, Transfers and Discharges”   The law establishes the procedures for admissions, transfers and discharges of patients....
105. Mass. Code Regs. 150.008. - Pharmaceutical Services and Medications “Pharmaceutical Services and Medications”   All facilities must maintain current written policies and procedures regarding the...
105. Mass. Code Regs. 150.013. - Clinical and Related Records “Clinical and Related Records”   All facilities must provide conveniently located and suitably equipped areas for the recording and...
105. Mass. Code Regs. 301.035. - Quality Assurance In order to assure the quality of the data submitted to the Cancer Registry, the health care facility and provider must allow the Cancer Registry to...
130. Mass. Code Regs. 405.412. - Recordkeeping Requirements A community health center must comply with the requirements set forth by the Department on recordkeeping.  The community health center must...
130. Mass. Code Regs. 433.409. - Recordkeeping (Medical Records) Requirements Payment for any service under Medicare or Medicaid or other medical assistance program is conditioned upon full and complete documentation in the...
Mass. Gen. Laws. Ann. ch. 111, §113. - Records of reports of dangerous diseases; notice “Records of reports of dangerous diseases; notice”   Every board of health shall keep a record of all reports received pursuant to...
Mass. Gen. Laws. Ann. ch. 112, § 12R - Written statement of reasons for abortion; tests on pregnant patients prior to abortions; various reports – “Written statement of reasons for abortion as required by Sec. 12M; tests on pregnant patients prior to abortions; report to commissioner,...
Required maintenance of medical records 101. Mass. Code Regs. 613.07. - Reporting Requirements Reporting Requirements   This section establishes the reporting requirements to the Health Safety Net Office from providers seeking payment for...
104. Mass. Code Regs. 27.17. - Records and Records Privacy “Records and Records Privacy”   This law sets forth how facilities shall maintain a permanent individual record for each person...
105. Mass. Code Regs. 130.347. - Discharge Planning Records “Discharge Planning Records”   The discharge planning service shall maintain written records which contain sufficient information to...
105. Mass. Code Regs. 145.500. - Medical Records Required for Each Patient “Medical Records Required for Each Patient”   A current medical record shall be maintained for every patient admitted to the out-of-...
105. Mass. Code Regs. 145.520. - Physician's Orders “Physician's Orders”   Physician orders shall be legibly entered into the medical record and shall be dated and signed by the...
105. Mass. Code Regs. 145.530. - Responsibility for Keeping Medical Records “Responsibility for Keeping Medical Records”   The unit shall designate a person to be in charge of keeping medical records in the...
105. Mass. Code Regs. 145.535. - Medical Record System “Medical Record System”   Each unit must develop a workable system for identifying, filing, indexing, and retrieving medical records...
105. Mass. Code Regs. 150.013. - Clinical and Related Records “Clinical and Related Records”   All facilities must provide conveniently located and suitably equipped areas for the recording and...
105. Mass. Code Regs. 170.345. - Records “Records”   Each service must prepare and maintain records that are subject to and available for inspection by the Department at any...
130. Mass. Code Regs. 433.409. - Recordkeeping (Medical Records) Requirements Payment for any service under Medicare or Medicaid or other medical assistance program is conditioned upon full and complete documentation in the...
130. Mass. Code Regs. 450.205. - Recordkeeping and Disclosure All providers (defined as “individual, group, facility, agency, institution, organization, or business that furnishes medical services and...
243. Mass. Code Regs. 2.07. - General Provisions Governing The Practice Of Medicine General Provisions Governing The Practice Of Medicine A physician must maintain adequate records for each patient.  The physician must keep the...
956. Mass. Code Regs. 8.06. - Recordkeeping “Recordkeeping”   Requiresschools maintain records sufficient to demonstrate compliance with 956 Mass. Code Regs. 8.00, including:...
Mass. Gen. Laws. Ann. ch. 111, §113. - Records of reports of dangerous diseases; notice “Records of reports of dangerous diseases; notice”   Every board of health shall keep a record of all reports received pursuant to...
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)) 104. Mass. Code Regs. 27.17. - Records and Records Privacy “Records and Records Privacy”   This law sets forth how facilities shall maintain a permanent individual record for each person...
105. Mass. Code Regs. 130.370. - Retention of Records A hospital must retain a patient’s records for at least 20 years from discharge or the patient’s last treatment.  The medical...
105. Mass. Code Regs. 131.208. - Patient Records - Request “Patient Records – Request”   After receiving a request to review a Medicare patient's discharge plan, the Advocacy Office,...
105. Mass. Code Regs. 140.302. - Patient Records Each health clinic must keep all patient records in a centralized location.  Each patient must have his or her own record with two forms of...
105. Mass. Code Regs. 145.555. - Release of Medical Record “Release of Medical Record”   Prior to release of any information from a medical record to any person not authorized by law to...
105. Mass. Code Regs. 150.014. - Utilization Review “Utilization Review”   This section establishes that facilities, which provide Level I or II caremust review the services, quality...
105. Mass. Code Regs. 300.191. - Access to Medical Records and Other Information The Department and local boards of health may obtain medical records and other information necessary to investigate, monitor, prevent the spread of...
105. Mass. Code Regs. 300.193. - Surveillance of Injuries Dangerous to Public Health “Surveillance of Injuries Dangerous to Public Health”   This section lists the types of injuries or causes of injuries the...
105. Mass. Code Regs. 302.050. - Medical Records Abstraction Abstractors must be qualified and trained to review and abstract medical records for the Congenital Abnormalities Registry.  Abstractors are...
105. Mass. Code Regs. 302.080. - Quality Assurance “Quality Assurance”   Physicians and health care facility must allow the Congenital Anomalies Registry to inspect and copy such...
105. Mass. Code Regs. 340.200. - Department Action to Control STD's “Department Action to Control STD's”   Upon notification by any source of an infected person or person suspected of being infected,...
110. Mass. Code Regs. 11.22. - Confidentiality of Medical Records and Information “Confidentiality of Medical Records and Information”   Medical records of a child must not be distributed or released to any...
243. Mass. Code Regs. 2.07. - General Provisions Governing The Practice Of Medicine General Provisions Governing The Practice Of Medicine A physician must maintain adequate records for each patient.  The physician must keep the...
958. Mass. Code Regs. 3.409. - Medical Records and Information “Medical Records and Information”   This section establishes how carriers shall make good faith efforts to obtain records relevant...
958. Mass. Code Regs. 3.409. - Medical Records and Information “Medical Records and Information”   This section establishes how carriers shall make good faith efforts to obtain records relevant...
Destruction, storage and filing of medical records (Cross reference with Security of Health Information) 104. Mass. Code Regs. 27.17. - Records and Records Privacy “Records and Records Privacy”   This law sets forth how facilities shall maintain a permanent individual record for each person...
105. Mass. Code Regs. 130.1410. - Quality Improvement Hospitals must implement a data driven quality assessment and performance improvement program for the Primary Stroke Service.  The hospital must...
105. Mass. Code Regs. 140.302. - Patient Records Each health clinic must keep all patient records in a centralized location.  Each patient must have his or her own record with two forms of...
105. Mass. Code Regs. 145.505. - Record Keeping Facilities and Equipment “Record Keeping Facilities and Equipment”   The unit must maintain facilities and equipment, appropriately located and adequate to...
105. Mass. Code Regs. 170.345. - Records “Records”   Each service must prepare and maintain records that are subject to and available for inspection by the Department at any...
105. Mass. Code Regs. 301.035. - Quality Assurance In order to assure the quality of the data submitted to the Cancer Registry, the health care facility and provider must allow the Cancer Registry to...
Retention periods 105. Mass. Code Regs. 130.370. - Retention of Records A hospital must retain a patient’s records for at least 20 years from discharge or the patient’s last treatment.  The medical...
105. Mass. Code Regs. 140.302. - Patient Records Each health clinic must keep all patient records in a centralized location.  Each patient must have his or her own record with two forms of...
130. Mass. Code Regs. 450.205. - Recordkeeping and Disclosure All providers (defined as “individual, group, facility, agency, institution, organization, or business that furnishes medical services and...
Medical Records Collection, Retention, and Access 130. Mass. Code Regs. 410.409. - Recordkeeping (Medical Records) Requirements Payment for any outpatient hospital services through MassHealth (Medicaid) is based on complete documentation in the patient’s medical record....
Mass. Gen. Laws. Ann. ch. 111, § 70 - Records of hospitals or clinics; custody; inspection; copies; fees Hospitals or clinics must retain medical records for 20 years after the discharge or the final treatment of a patient. Hospitals and clinics are the...
Mass. Gen. Laws. Ann. ch. 111, § 70D - Itemized statement of charges; effect of failure to furnish If a patient submits a written request for an itemized bill from the hospital, the hospital must furnish the itemized list within 10 days of the...
Mass. Gen. Laws. Ann. ch. 111, § 70E - Patients' and residents' rights All of the rights below apply to all patients in all facilities.  This section applies to all health care facilities, which include, hospitals,...
Mass. Gen. Laws. Ann. ch. 111, § 72 - Classification of convalescent and nursing homes, infirmaries, etc.; rules and regulations The statute expressly states that the rules and regulations for convalescent and nursing homes must include the minimum requirements for medical and...
Mass. Gen. Laws. Ann. ch. 175I, § 8 - Recorded personal information; medical record information; disclosure; fees An insurance company must make any personal information collected about an individual available to the individual to whom it refers.  An...
Mass. Gen. Laws. Ann. ch. 66A, § 2 - Holders Maintaining Personal Data System; Duties All holders of personal data systems must hold one person responsible for the prevention of access and dissemination of personal data, including...