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Medical Records Collection, Retention, and Access in Ohio

Ohio law governs the collection, retention and access of medical records across provider types and facilities.  As a condition of licensure, the following facilities and programs must maintain medical records for every patient for the designated time period.  Each health care facility1 must maintain records for six years from the date of discharge, documenting the patient’s needs and assessments and services rendered.2  The provider of a health care service3 must maintain records for five years from the date of discharge; such record must document the patient’s needs and assessments and services rendered.4  Each residential care facility must maintain records for seven years following the date of the resident’s discharge.5  Every nursing home must maintain records for seven years following the date of the resident’s discharge.6  Each freestanding or mobile diagnostic imaging center must maintain all records for six years from the date of service.7  Adult care facilities must maintain a record for two years after the resident is permanently transferred, discharged, or dies.8

Some providers are required to document certain elements about the patient in the patient’s medical record.  Health care facility records9 and ambulatory surgical facility records10 must document the name, address, date of birth, gender, and race or ethnicity of the patient.  Every nursing home record must document the patient’s name, age, sex, race/ethnicity, and religion.11    

Ohioans have the right to access their health care records. In order examine or obtain a copy of all or part of one’s medical record, a patient, his personal representative or an authorized person must submit such a request in writing to the provider; the provider must comply with the request unless disclosure would be medically contraindicated, in which case the provider will provide the record to a designated physician or chiropractor.  A patient, his personal representative or an authorized person may bring a civil action against any provider who fails to furnish a medical record to enforce the patient’s right of access to the record.12  Managed health care program members have the right to request and receive a copy of their medical records.13

All pharmacies must maintain a patient profile system, and the dispensing pharmacist will be responsible for ensuring that a reasonable effort has been made to obtain, document and maintain the patient’s data record and the patient’s drug therapy record for all of the prescriptions that were filled at the pharmacy within the last twelve months; the patient profile shall be maintained for at least one year from the date of the last entry in the profile record.14  All records relating to the practice of pharmacy, including prescription information entered into the record-keeping system, prospective drug utilization review, patient counseling and prescription information must be uniformly maintained for three years.15  A person having custody of or access to records relating to the practice of pharmacy, the administration of drugs, or any patient-specific drug transaction may disclose the contents of the records, or provide a copy of the records, to the patient for whom the prescription or medication order was issued.16

 

Footnotes

  • 1. Note: The definition of a health care facility (HCF) is located in Ohio Admin. Code 3701-83-01(I) “General definitions”.
  • 2. Ohio Admin. Code 3701-83-11
  • 3. Note: a health care service is defined in Ohio Admin. Code 3701-84-01(K) “General Definitions”.
  • 4. Ohio Admin. Code 3701-84-11
  • 5. Ohio Admin. Code 3701-17-67
  • 6. Ohio Admin. Code 3701-17-19
  • 7. Ohio Admin. Code 3701-83-54
  • 8. Ohio Admin. Code 5122-33-15
  • 9. Ohio Admin. Code 3701-83-23.3
  • 10. Ohio Admin. Code 3701-83-21
  • 11. Ohio Admin. Code 3701-17-19
  • 12. Ohio Rev. Code Ann. § 3701.74
  • 13. Ohio Admin. Code 5101:3-26-08.3
  • 14. Ohio Admin. Code 4729-5-18
  • 15. Ohio Admin. Code 4729-5-27
  • 16. Ohio Admin. Code 4729-5-29

 

Medical Records Collection, Retention, and Access in Ohio

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