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