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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

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