California law requires that medical records be kept for all hospital patients for at least seven years.  Hospital medical records must be promptly authenticated or signed by a licensed health care professional.1  The law also sets forth the required elements of the patient’s inpatient record, including demographic information, identifying information, clinical information, as well as information regarding the patient’s religion.2  California hospitals are required to maintain a medical record service, which should be conveniently located and adequate in size.3  California also requires hospitals to maintain an emergency care data record for each patient in the hospital’s emergency department, which must record the patient’s identifying information, ethnicity, principal language spoken, and clinical information.4  Similar recordkeeping is required for freestanding ambulatory surgical clinics.5

The law also requires nursing facilities to maintain medical records for each patient.  The records must be kept for seven years after the patient is discharged from the facility.  If the patient is a minor, the records must be kept for one year after the patient reaches the age of 18, but for at least seven years.  Information in the medical record must remain confidential and can be disclosed only to authorized federal, state or local government agents.  The patient health record cannot be removed from the facility unless the record is being moved into an offsite storage facility after the patient has been discharged.6  

California law has similar requirements for community health centers.  A separate, current and complete record must be maintained for each patient/client admitted into a community health center.  The patient’s record must be retained for at least three years after termination of service to the patient.  Each record must contain the patient’s identifying information as well as demographic and medical information, such as a medical assessment, a signed copy of the admissions agreement, and medications taken.  The community health center must ensure that all information remains confidential.7

California’s  laws apply to all health care facilities, without differentiating by type of facility.  For example, all health care providers, health plans, and pharmaceutical companies must preserve and store medical records in a way that preserves confidentiality.8  In addition, one of the key reporting requirements for all licensed health care facilities in California is that all such facilities, including primary care clinics and/or long term care clinics, are required to record the patient’s principal spoken language in the patient’s health record.9

Notably, California does not have recordkeeping requirements that are specific to physicians.  This is contrary to most other state professional licensing laws.  California does, however, have specific recordkeeping requirements that apply to Medi-Cal (the state’s Medicaid program) participating providers.10  Similarly, health plans that administer Medi-Cal are required to maintain records for Medi-Cal beneficiaries, and must retain these records for at least five years.11

California law also regulates access to medical records by patients or patient representatives.  Health care providers are legally obligated to allow patients or patient representatives to inspect their medical records within five days of a written request.  Patients or their representatives are also entitled to copies of their medical records upon written request.  The law does allow providers to charge a reasonable fee for costs incurred, but does not allow fees to be charged for Medicaid patients requesting copies to support an appeal regarding eligibility.12^,13  A patient who inspects his or her medical record and finds inaccuracies also has the right to provide the health care provider with a written addendum, which must be attached to the patient’s medical record.14