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Medical Records Collection, Retention, and Access in Pennsylvania

        The requirements for maintaining medical records in Pennsylvania vary depending on the type of provider or health care facility.  For instance, all physicians (including osteopathic physicians1) must maintain medical records for patients for at least seven years after the date of the last medical service provided, or for one year after majority for minor patients.2  For hospitals, records must be maintained for seven years following discharge, or for seven years following the age of majority for minority patients.3  The seven year requirement applies to long term care facilities4 as well as birthing centers5

        Other facilities may have shorter periods of time for which they must keep patient records.  Psychologists must maintain a record for each client seen for a period of at least five years.6  Adult daily living centers must keep client records7, and maintain them for at least four years after a client’s departure8  The client record must include specific information about the client, including his or her race, sex and primary language.9

        More generally, the law sets forth the specific facilities and providers (in addition to those listed above) that must maintain medical records.  The record keeping requirements are especially focused on providers providing medical care to recipients of medical assistance.10  Other facilities that are required to maintain medical records include ambulatory surgical facilities,11 hospital pharmacies,12 emergency service providers,13 hospital outpatient service providers,14 home health agencies,15 and laboratories.16

        Pennsylvania also has laws requiring a patient’s access to information contained in or the actual medical record.  These rights apply to hospital patients, and are found in the Patient’s Bill of Rights,17 as well as to patients of ambulatory surgery facilities.18  Clients of adult daily living centers19 and of birthing centers20 also have the right to access their medical records.

 

Footnotes

  • 1. 49 Pa. Code § 25.213
  • 2. 49 Pa. Code § 16.95
  • 3. 28 Pa. Code § 115.23; 28 Pa. Code, Part IV, Subchapter B
  • 4. 28 Pa. Code § 211.5
  • 5. 28 Pa. Code § 501.62
  • 6. 49 Pa. Code §41.57
  • 7. 6 Pa. Code §11.192
  • 8. 6 Pa. Code § 11.195
  • 9. 6 Pa. Code §11.193
  • 10. 55 Pa. Code §1101.51
  • 11. 28 Pa. Code, Chapter 563
  • 12. 28 Pa. Code §113.23
  • 13. 28 Pa. Code §117.43
  • 14. 28 Pa. Code §119.24
  • 15. 28 Pa. Code §601.36
  • 16. 28 Pa. Code, Chapter 5
  • 17. 28 Pa. Code §103.22
  • 18. 28 Pa. Code, Chapter 563
  • 19. 6 Pa. Code §11.197
  • 20. 28 Pa. Code §501.46

 

Medical Records Collection, Retention, and Access in Pennsylvania

Subtopic Statute/Regulation Description
Medical Records Collection, Retention, and Access Access - 6 Pa. Code § 11.197 Clients of older adult daily living centers will have access to their own records and the information contained therein, unless, in the opinion of...
Clinical records - 28 Pa. Code § 211.5 Long term care facility’s clinical records must conform to the following requirements: Information contained in the resident’s record...
Clinical records - 28 Pa. Code § 601.36 Providers of home health care services must maintain a clinical record containing pertinent past and current findings for every patient receiving...
Confidentiality - 28 Pa. Code § 5.53 Records and reports of examinations of specimens are confidential. 28 Pa Code Chapter 5, “Confidentiality” § 5.53
Confidentiality - 40 Pa. Stat. Ann. § 991.2131 Managed care plans and utilization review entities must ensure that all identifiable information regarding enrollee health, diagnosis and treatment...
Confidentiality of medical records - 28 Pa. Code § 115.27 Medical record confidentiality
Confidentiality of medical records - 28 Pa. Code § 563.9 Records should be confidential
Content of records - 6 Pa. Code § 11.193 Every older adult daily living center records must include the following information about the client: Identifying information, including name,...
Contents - 28 Pa. Code § 115.32 Medical record contents
Contents of records - 28 Pa. Code § 5.52 The record must identify the person from whom the specimen was taken and include the result of the test. 28 Pa Code Chapter 5, “Contents of...
Form and content of record - 28 Pa. Code § 563.12 Ambulatory surgical facilities must maintain a separate medical record for each patient that includes the following information:1   ...
Health record transfer, retention and confidentiality - 28 Pa. Code § 501.62 Birth centers must comply with the following requirements pertaining to patient medical records: If a patient is transferred or referred to...
Implementation - 28 Pa. Code § 103.22 All hospitals must establish a Patient’s Bill of Rights that contains the following provisions relating to patients: The right, upon...
Individual Record - 6 Pa. Code § 11.192 Each older adult daily living center must keep an individual record for each client.
Medical records - 28 Pa. Code § 117.43 A medical record shall be kept for every patient receiving emergency service, including: Patient identification data; Time of arrival; By...
Medical records - 49 Pa. Code § 16.95 Physicians must maintain medical records for patients that accurately and completely reflect the evaluation and treatment of the patient and clearly...
Medical records - 49 Pa. Code § 25.213 Every osteopathic physician must maintain a medical record for each patient that identifies the patient and provides pertinent clinical information,...
Medical records review - 28 Pa. Code § 115.34 Medical records review
Ongoing responsibilities of providers- 55 Pa. Code § 1101.51 Recipients of medical assistance may obtain services from any institution, agency, pharmacy, person or organization that is approved by the...
Ownership - 28 Pa. Code § 115.28 Hospital medical records are the property of the hospital and may only be removed from the hospital premises for court purposes. Copies may be made...
Ownership - 28 Pa. Code § 563.10 Ambulatory surgical facilities must maintain a separate medical record for each patient that includes the following information: 28 Pa. Code Chapter...
Patient Access - 28 Pa. Code § 115.29 These requirements apply to hospitals.  A patient or his or her designee must be given access to or a copy of their medical records, or both, in...
Patient access - 28 Pa. Code § 563.11 Access to copies of medical records
Patient care records - 28 Pa. Code § 127.35 Patient care records
Patient dental records - 28 Pa. Code § 141.26 Dental records
Patient medical records - 28 Pa. Code § 115.31 All hospitals must maintain patient records in accordance with the following provisions:         A medical...
Patient medical records - 28 Pa. Code § 119.24 Outpatient services in hospitals must maintain an accurate medical record for every patient; outpatient service records must be made a part of the...
Patient medical records - 28 Pa. Code § 121.16 Patient medical records
Patient records - 28 Pa. Code § 129.37 Patient records
Patients’ medical records - 28 Pa. Code § 131.24 Patient medical records
Patient’s rights - 28 Pa. Code § 501.46 Birthing centers must have written policies and procedures that provide the following rights to patients: Right to confidentiality, anonymity and...
Preservation of medical records - 28 Pa. Code § 115.23 Preservation of medical records
Preservation of medical records - 28 Pa. Code § 563.6 Policies regarding medical record retention
Professional records - 49 Pa. Code § 41.57 Psychologists must maintain a record for each client, which includes, at a minimum: The name and address of the client/patient and, if the client...
Record retention - 6 Pa. Code § 11.195 Older adult daily living centers’ client records must be kept for four years after a client’s departure, or until audits or litigation...
Recordkeeping - 6 Pa. Code § 21.60 Each area agency on aging providing domiciliary care services must maintain a case record for each client receiving services; these records must...
Records - 28 Pa. Code § 113.23 Hospital pharmacies must maintain the following:         A record of all drug transactions, correlated with...
Records - 28 Pa. Code § 561.22 Ambulatory surgical facilities must provide pharmaceutical services; drug transactions of such services must be recorded, and those records must be...
Report of findings - 28 Pa. Code § 5.47 A clinical laboratory may only report its findings to the person who submitted the specimen or requested the analysis, or to health officials as...
Reportable diseases - 28 Pa. Code § 5.49 The director of the laboratory must report to the department of health all findings which indicate the presence of any reportable disease. 28 Pa....
Retention of reports - 28 Pa. Code § 5.51 Each laboratory must keep a record of test results for each specimen; if the laboratory is part of a hospital, the permanent laboratory record may be...
Storage of medical records - 28 Pa. Code § 115.22 Storage of medical records
Unprofessional and immoral conduct - 49 Pa. Code § 16.61 A Board-regulated practitioner who engages in unprofessional or immoral conduct is subject to disciplinary action. Unprofessional or immoral conduct...