Skip to Content

Medical Records Collection, Retention, and Access in Washington

        Washington law requires that health care providers maintain existing patient health care records for at least 1 year following an authorization to disclose that health care information, and during a pending request for examination and copying or request for correction or amendment.1  A subgroup of providers, podiatrists, are also required to maintain records on each patient, by law.  These records should be kept for a minimum of seven years.2  Chiropractors are also subject to the recordkeeping requirement in the state of Washington.  Any chiropractor who treats patients must maintain all treatment records regarding patients treated.  The record includes (but is not limited to) X rays, treatment plans, patient charts, patient histories, correspondence, financial data, and billing.  Medical records must be retained by chiropractors,3 denturists,4 and opticians5 for five years in an orderly, accessible file, and must be readily available for inspection by the commission.  The state’s Death with Dignity Act requires health care providers to document specific elements in a patient’s medical record, such as the patient’s request for medication to end his or her life, physician’s diagnosis or prognosis, and records of counseling.6

        Washington has instituted laws regarding hospital retention of patient medical records.  The law requires that hospitals have a medical record for each patient treated7 and retain all medical records for at least 10 years following the most recent discharge of the patient, with the exception of minor patients.  For minor patients, the record needs to be retained and preserved for a period of at least three years following the patient’s eighteenth birthday, or ten years following the latest discharge – whichever is longer.8

        Nursing homes are also required to maintain clinical records on each resident by law.  The records must be complete, accurately documented, readily accessible, and systematically organized.  Nursing homes must safeguard the record against alteration, loss, destruction and unauthorized use, and keep confidential all information contained in the resident’s records.  Each facility should designate an individual who is responsible for the record system, and has appropriate training and experience in clinical record management.9  Washington law requires nursing homes to retain and preserve all medical records which relate directly to the care and treatment of a patient for at least eight years following the most recent discharge of the patient, with the exception of minor patients.  For minor patients, the record needs to be retained and preserved for a period of at least three years following the patient’s eighteenth birthday, or ten years following the latest discharge – whichever is longer.10

        Washington also has provision for hospice care centers that require each center to maintain a current record for each patient.  The record must be accessible, in an integrated document in the center’s office site for review by appropriate personnel, and in chronological order.  The content of the record must include patient identifying information, financial information, insurance information, and clinical information.  All records should be kept for at least three years following the date of termination for adults, and either three years after attaining the age of 18 or five years following discharge, whichever is longer, for minors.11

        Birth centers in the state of Washington must have a defined client record system, policies, and procedures, which provide for identification, security, confidentiality, control, retrieval, and preservation of client care data and information.  Each mother and newborn must have a health record that includes such information as demographic data, the client’s informed consent, signed notes regarding the newborn and maternal status, consultation reports, lab and diagnostic tests and referrals.  All client records must be kept for three years following the date of termination of services for adults, and three years after attaining the age of 18 or five years after discharge for minors.12

        Washington also regulates chemical dependency service providers.  Such service providers must maintain records on each patient.  The providers must ensure that these records include patient demographic data, a chemical dependency assessment and history of involvement with alcohol and other drugs, documentation of the patient’s response when asked if the patient is under either court order or Department of Corrections supervision, documentation that the patient was informed of confidentiality requirements and diagnostic assessments,  voluntary consent to treatment, treatment plans, weekly individualized documentation of ongoing services, any medication or lab reports, patient correspondence, tuberculosis test results, documentation of HIV/AIDS risk intervention, and the discharge summary.13  All patient records must be kept for a minimum of six years after the discharge or transfer of the patient.14

        The state also regulates patient medication records maintained by a pharmacy.  Pharmacies may maintain their records manually or electronically.  Both record systems must capture basic data, such as patient identification, drug information, prescriber information, dispenser information, and other relevant patient information.15  Pharmacies using electronic records are also required to have auxiliary recordkeeping procedures in place as a backup to the electronic system.16  Pharmacies must retain patient medication information for at least two years.17  

        The state of Washington gives patients strong rights to have access to their medical records.  Health care providers must allow patients to examine their health care information and provide them with copies, upon written request.  However, a health care provider may deny access to the patient under a few, limited circumstances.18  Providers may charge a reasonable fee for duplicating a patient’s health record.19  Once access to the medical record has been provided, the provider or facility must certify that the record was in fact furnished.  The certification should be attached to the record, and must include certain information about the patient and the information requested.20  Patients also have the right to request that a health care provider amend or correct health information in the patient’s medical record,21 and to be given an estimate of fees or charges related to a particular health care service.22

           

 

Footnotes

  • 1. Wash. Rev. Code §70.02.160
  • 2. Wash. Admin. Code §246-922-260
  • 3. Wash. Admin. Code §246-808-650
  • 4. Wash. Admin. Code §246-812-320
  • 5. Wash. Admin. Code §246-824-220
  • 6. Wash. Rev. Code § 70.245.120
  • 7. Wash. Admin. Code §246-320-166
  • 8. Wash. Rev. Code §70.41.190
  • 9. Wash. Rev. Code § 74.42.420; Wash. Admin. Code §388-97-1720
  • 10. Wash. Rev. Code §18.51.300
  • 11. Wash. Admin. Code §246-335-110
  • 12. Wash. Admin. Code §246-329-140
  • 13. Wash. Admin. Code §388-805-325
  • 14. Wash. Admin. Code §388-805-320
  • 15. Wash. Admin. Code §246-875-020; Wash. Admin. Code §246-875-030
  • 16. Wash. Admin. Code §246-875-050
  • 17. Wash. Admin. Code §246-875-070
  • 18. Wash. Rev. Code §70.02.80; Wash. Rev. Code §70.02.90
  • 19. Wash. Admin. Code §246-08-400
  • 20. Wash. Rev. Code §70.02.70
  • 21. Wash. Rev. Code §70.02.100; Wash. Rev. Code §70.02.110
  • 22. Wash. Rev. Code §70.01.30

 

Medical Records Collection, Retention, and Access in Washington

Subtopic Statute/Regulation Description
Medical Records Collection, Retention, and Access Wash. Admin. Code § 246-335-110 Content of Hospice Care Center Services Client Records Hospice Care Centers must maintain a current record for each patient.  The record must be...
Wash. Rev. Code § 70.02.090 Patient's request — Denial of examination and copying Health care providers may deny a patient access to their health care information if the...
Wash. Admin. Code § 246-08-400 Reasonable Charges for Duplicating Patient Records A health care provider may charge reasonable fees for duplicating a patient record.  For the...
Wash. Admin. Code § 246-320-166 Hospital Management of Patient Information Hospitals must provide medical staff, employees and other authorized persons with access to patient...
Wash. Admin. Code § 246-329-140 Content of Childbirth Center Clinical Records Birth centers must have a defined client record system, policies, and procedures, which provide for...
Wash. Admin. Code § 246-808-650 Maintenance of Patient Records by Chiropractors Any chiropractor who treats patients must maintain all treatment records regarding patients treated....
Wash. Admin. Code § 246-812-320 Maintenance of Patient Records by Denturists Any denturist who treats patients must maintain complete treatment records regarding patients treated....
Wash. Admin. Code § 246-824-220 Maintenance of Patient Records by Opticians Practitioners must maintain contact lens records for a minimum of 5 years.  The records must include...
Wash. Admin. Code § 246-875-020 Minimum Required Information in an Pharmacy Automated Patient Medication Record System An automated patient medication record system is an electronic...
Wash. Admin. Code § 246-875-030 Minimum Required Information in an Pharmacy Manual Patient Medication Record System A manual patient medication record system consists of the hard...
Wash. Admin. Code § 246-875-050 Auxiliary Pharmacy Recordkeeping Procedures If an automated data processing system is used to maintain a patient’s medication record, there...
Wash. Admin. Code § 246-875-070 Confidentiality and Security of Pharmacy Patient Medication Record Systems Information that is contained in patient medication record systems must be...
Wash. Admin. Code § 246-922-260 Maintenance of Patient Records by Podiatrists Any podiatric physician and surgeon who treats patients must maintain complete and legible treatment...
Wash. Admin. Code § 388-805-320 Requirements of Patient Record Systems for Chemical Dependency Service Providers Each Chemical Dependency Service Provider must have a comprehensive...
Wash. Admin. Code § 388-805-325 Content of Chemical Dependency Service Providers Patient Records Service providers must ensure that all patient records include patient demographic...
Wash. Admin. Code § 388-97-1720 Content of Nursing Home Clinical Records Nursing homes must maintain clinical records on each resident.  The records must be complete,...
Wash. Rev. Code § 18.51.300 Nursing Home Retention and Preservation of Patient Records A nursing home must retain and preserve all medical records which relate directly to the...
Wash. Rev. Code § 51.14.120 Copy of claim file — Notice of protest or appeal — Medical report Washington requires all self-insured employers to provide their injured...
Wash. Rev. Code § 70.02.070 Certification of the Patient Health Record Upon a request by the person requesting the record, the provider or facility must certify the record...
Wash. Rev. Code § 70.02.080 Patients’ Access to Health Care Records A patient may submit a written request to examine or copy all or part of the patient's recorded health...
Wash. Rev. Code § 70.02.100 Correction or Amendment of the Record A patient may request in writing that a health care provider correct or amend the health care information in a...
Wash. Rev. Code § 70.02.110 Correction or amendment or statement of disagreement — Procedure If a health care provider agrees to amend or correct a health care record, the...
Wash. Rev. Code § 70.02.120 Notice of Information Practices to be Displayed Conspicuously Health care providers that operate a health care facility, and who maintain a record of...
Wash. Rev. Code § 70.02.160 Retention of the Patient Health Care Record Health care providers must maintain existing patient health care records for at least one year following...
Wash. Rev. Code § 70.02.170 Civil remedies A person who has complied with the relevant requirements governing health care information access and disclosure may bring an action...
Wash. Rev. Code § 70.245.120 Medical record documentation requirements The Washington Death with Dignity Act requires physicians to document or insert the following items in...
Wash. Rev. Code § 70.41.190 Hospital Retention and Preservation of Patient Records A hospital must retain and preserve all medical records which relate directly to the care and...
Wash. Rev. Code § 70.58.270 Data on inmates of hospitals, etc. All institutions that treat, confine, or commit individuals pursuant to a court order must keep recordsof the...
Wash. Rev. Code § 70.97.200 Recordkeeping — Compliance with state, federal regulations — Health care information releases Enhanced service facilities must (1) keep...
Wash. Rev. Code § 71.05.420 Records of disclosure The physician or psychiatric advanced registered nurse practitioner in charge of a patient or the head of the facility caring...
Wash. Rev. Code § 71.32.140 Refusal of admission to inpatient treatment — Effect of directive An individual that (1) executes a mental health advanced directive that is...
Wash. Rev. Code § 71.32.150 Compliance with directive — Conditions for noncompliance Health care providers, professionals, facilities, and their agents must place a person...
Wash. Rev. Code § 71.34.520 Minor voluntarily admitted may give notice to leave at any time Minors may, at any time, give notice of their intent to leave a mental health...
Wash. Rev. Code § 74.42.420 Resident Record System Nursing homes must establish an organized record system to house resident records. These records must include: (1) the...