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Medical Records Collection, Retention, and Access in Rhode Island

Medical Records Collection, Retention, and Access

Rhode Island requires health care providers to document numerous items in patient medical records (e.g. informed consent for HIV testing1 and abortions,2 diagnoses of Lyme disease,3 and the existence of a power of attorney).4 Other individuals and entities with medical recordkeeping requirements include assisted living residences,5 employers,6 department of behavioral healthcare, developmental disabilities, and hospitals,7 and home nursing care providers.8

Rhode Island allows patients to access, inspect, and request amendments of their confidential health information held by third parties9 and Rhode Island’s Health Information Exchange.10 Health care providers must transfer copies of diagnostic tests to other health care providers pursuant to a patient’s written request.11 Third parties may transfer confidential health care information to a designated physician upon the occurrence of an event that adversely affects the patient based on their health information (e.g. denial of an insurance application or benefit claim).12 Physicians must publish notice regarding the disposition of patient medical records upon the closing of their practice.13

 

Footnotes

  • 1. Gen.Laws 1956, § 23-6.3-3.
  • 2. Gen.Laws 1956, § 23-4.7-3; Gen.Laws 1956, § 23-4.7-4.
  • 3. Gen.Laws 1956, § 5-37.5-4.
  • 4. Gen.Laws 1956, § 23-4.10-3; Gen.Laws 1956, § 23-4.10-4.
  • 5. Gen.Laws 1956, § 23-17.4-15.3.
  • 6. Gen.Laws 1956, § 23-1.11-8.
  • 7. Department formally known as the “department of mental health, retardation and hospitals.”
  • 8. Gen.Laws 1956, § 23-17.16-4.
  • 9. Gen.Laws 1956, § 5-37.3-5.
  • 10. Gen.Laws 1956, § 5-37.7-10.
  • 11. Gen.Laws 1956, § 5-37.3-5.1.
  • 12. Gen.Laws 1956, § 5-37.3-5.
  • 13. Gen.Laws 1956, § 5-37-30.

 

Medical Records Collection, Retention, and Access in Rhode Island

Subtopic Statute/Regulation Description
Medical Records Collection, Retention, and Access Abuse - R.I. Gen. Laws Ann. § 23-17.5-9 Rhode Island permits the physical restraint of nursing home patients only in emergencies or when “authorized in writing by a physician for a...
Care by physician – Disclosure of patient's medical condition - R.I. Gen. Laws Ann. § 23-17.5-6 Nursing home patients must be cared for by physicians in accordance with nursing home policies. Physicians must inform nursing home patients of their...
Closure of medical practice- Preservation of records - R.I. Gen. Laws Ann. § 5-37-30 At least 90 days before closing their practice, a physician must provide public notice in a statewide newspaper regarding the disposition of patient...
Controlled substances - R.I. Gen. Laws Ann. § 5-37.4-3 Practitioners may prescribe, administer, and dispense controlled substances to persons diagnosed with “a condition resulting in intractable...
Declaration relating to use of life sustaining procedures - R.I. Gen. Laws Ann. § 23-4.11-3 Rhode Island permits individuals aged 18 and older to “execute a declaration governing the withholding or withdrawal of life sustaining...
Diagnostic tests – Transfer and access - R.I. Gen. Laws Ann. § 5-37.3-5.1 Health care providers must transfer copies of diagnostic tests to other health care providers pursuant to a patient’s written request....
Disclosures - R.I. Gen. Laws Ann. § 5-37.22 These requirements apply to physicians and physician practice groups.  Unless otherwise expressly stated in writing by a medical practice group...
Emergency requiring immediate action - R.I. Gen. Laws Ann. § 23-4.7-4 Physicians do not need to obtain informed consent for an abortion in an emergency situation that requires immediate action. Under such circumstances...
HIV screening and testing of adults, adolescents, and pregnant women - R.I. Gen. Laws Ann. § 23-6.3-3 All health care settings and HIV counseling, testing and referral services (HIV CTRS) must comply with the following provisions: HIV screening...
Long-term antibiotic treatment - R.I. Gen. Laws Ann. § 5-37.5-4 Physicians may prescribe, administer, and dispense antibiotics to persons with Lyme disease so long as the physician documents the diagnosis and...
Medical orders for life sustaining treatment - R.I. Gen. Laws Ann. § 23-4.11-3.1 The department of health must create rules for establishing “Medical Orders for Life Sustaining Treatment” (MOLST) and rules regarding...
Medical Records - CRIR 14-090-007, § 27.12 Medical Records  A medical record must be created and maintained for every person treated on an inpatient, outpatient (ambulatory) or...
Pain assessment - R.I. Gen. Laws Ann. § 5-37.6-4 Health care providers and facilities must regularly assess a patient’s pain level and record it in the patient’s chart.
Patients' visitation rights - R.I. Gen. Laws Ann. § 23-17.19-3 Patients may designate a maximum of five non-related individuals to receive full visitation rights during the patients’ inpatient stay....
Patient’s rights - R.I. Gen. Laws Ann. § 5-37.7-10 Patients whose confidential health information is transferred on Rhode Island’s Health Information Exchange have the right to: (1) “...
Recording contents of durable power of attorney - R.I. Gen. Laws Ann. § 23-4.10-4 An attending physician that learns of a patient’s durable power of attorney must document its existence in the patient’s medical records...
Recording determination of terminal condition and contents of declaration - R.I. Gen. Laws Ann. § 23-4.11-5 An attending physician that has notice of a patient’s declaration regarding the use of life sustaining procedures and determines that the...
Records and reports as to institution residents - R.I. Gen. Laws Ann. § 40.1-2-6 The department of behavioral healthcare, developmental disabilities, and hospitals1 must maintain records for every individual institutionalized in...
Required disclosures - R.I. Gen. Laws Ann. § 23-4.7-3 Physicians, prior to performing an abortion, must (1) inform the woman that she is pregnant and estimate the current age of the fetus; (2) explain...
Resident immunization - R.I. Gen. Laws Ann. § 23-17.19-4 Long-term care facilities must document that each resident has received an annual immunization against influenza and pneumococcal disease.  
Resident records - R.I. Gen. Laws Ann. § 23-17.4-15.3 Records regarding residents of assisted living residences must include a list of medications taken by each resident, information about the resident...
Revocation - R.I. Gen. Laws Ann. § 23-4.10-3 A person may revoke their durable power of attorney “at any time and in any manner by which [they are] able to communicate an intent to revoke...
Revocation of declaration - R.I. Gen. Laws Ann. § 23-4.11-4 An individual may revoke a declaration relating to the use of life sustaining procedures “at any time and in any manner by which [they are]...
Services; Medical Records - 31-5-41 R.I. Code R. § 11 A patient or an authorized representative may request the patient's medical records and medical bills from a physician, and must submit such requests...
Sharps injury log - R.I. Gen. Laws Ann. § 23-1.11-8 Employers must maintain a sharps injury log that contains information regarding (1) the type of device involved in the injury incident; (2) the...
Transfer and amendment of information - R.I. Gen. Laws Ann. § 5-37.3-5 If a third party action or decision that is based on a patient's confidential health care information adversely affects a patient, such as denial of...
Transfer and amendment of information - R.I. Gen. Laws Ann. § 5-37.3-5 A third party may transfer a patient’s confidential health care information to a designated physician upon the occurrence of an event that...
Transfer to another facility - R.I. Gen. Laws Ann. § 23-17.5-17 Nursing homes must give patients notice of their need for transfer to another facility and alternatives to transfer. If the transfer is to a facility...
Written notice of rights of home care patients/clients - R.I. Gen. Laws Ann. § 23-17.16-4 Home nursing care providers and agencies must provide their patients/clients with written notice of the patient/client rights before providing care...