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Medical Records Collection, Retention, and Access in Connecticut

Medical Records Collection, Retention, and Access

Licensed health care professionals must comply with the following medical record requirements:

· Providers in facilities that treat persons with psychological disabilities must record orders for seclusion or restraint,1 examination reports,2 and certain restrictions3 in patient medical records.

· Psychiatrists, psychologists, and social workers must justify their decision to treat a minor without parental consent in the minor’s clinical record.4

· Hospitals must place a “complete occupational history” of each patient diagnosed with cancer in that patient’s medical record.5

· Short-term general hospitals, out-patient surgical facilities and outpatient clinics must include E-codes in the medical records of trauma patients and inpatients6 and the circumstances and results of alcohol and substance abuse screening in every trauma patient’s medical record.7

· Pharmacists must document verbal medication orders in patient charts,8 maintain records of oral and electronic prescriptions,9 and document the administration of medication pursuant to a drug therapy agreement in patient medical records.10

Connecticut allows access to medical records in the following circumstances:

· Patients and their attorneys when pursuing litigation following the patient’s release from a facility that treats psychological disorders.11

· The Long-Term Care Ombudsman upon receiving a patient’s consent.12

· Patients and their representatives may access records maintained by licensed health care institutions upon written request.13

· Patients and their representatives may access provider maintained health records upon written request. 14

 

Footnotes

  • 1. C.G.S.A. § 17a-544.
  • 2. C.G.S.A. § 17a-545.
  • 3. C.G.S.A. §§ 17a-546- 17a-548.
  • 4. C.G.S.A. § 19a-14c.
  • 5. C.G.S.A. § 19a-73.
  • 6. C.G.S.A. § 19a-490e.
  • 7. C.G.S.A. § 19a-490h.
  • 8. C.G.S.A. § 19a-509d.
  • 9. C.G.S.A. § 20-614; C.G.S.A. § 20-615; C.G.S.A. § 20-620.
  • 10. C.G.S.A. § 20-631; C.G.S.A. § 20-631a.
  • 11. C.G.S.A. § 17a-548.
  • 12. C.G.S.A. § 17b-410.
  • 13. C.G.S.A. § 19a-490b.
  • 14. C.G.S.A. § 20-7c. 

 

Medical Records Collection, Retention, and Access in Connecticut

Subtopic Statute/Regulation Description
Medical Records Collection, Retention, and Access Access to medical records; Notification to patient of certain test results; Authority of provider to withhold information - Conn. Gen. Stat. § 20-7c Except as otherwise provided, a health care provider must give a patient all current information regarding a treatment of diagnosis, upon the patient...
Collaborative drug management agreements between pharmacists employed by community pharmacies and one or more physicians. Pilot program - Conn. Gen. Stat. § 20-631a The Commissioner of Consumer Protection must, after consulting with the Commission of Pharmacy, establish a pilot program that allows a maximum of 10...
Communication by mail and telephone - Conn. Gen. Stat. § 17a-546 Patients hospitalized in facilities that treat psychological disabilities must have the opportunity to communicate via sealed mail and the telephone...
Emergency room screening of trauma patients for substance abuse. Assistance by and reporting to the Department of Mental Health and Addiction Services - Conn. Gen. Stat. § 19a-490h Short-term general hospitals, outpatient surgical facilities, and outpatient clinics must include the circumstances and results of alcohol and...
Furnishing of health records and veterans' information. Access to tissue slides or blocks. Certified document re storage of and access to health records upon cessation of operations - Conn. Gen. Stat. § 19a-490b Licensed health care institutions must provide patients access to their health record upon receiving written request from the patient, their...
Long-term hospitals: chronic disease hospital - CONN. AGENCIES REGS § 19-13-D5 Long-term hospital buildings should be of sound construction and provide adequate accommodations for patients. The hospital should be in good repair...
Occupational history of cancer patients in hospital medical records. Regulations - Conn. Gen. Stat. § 19a-73 Hospitals must place a “complete occupational history” of each patient diagnosed with cancer in that patient’s medical record....
Patient's rights re clothing, possessions, money and access to records. List of rights to be posted - Conn. Gen. Stat. § 17a-548 Patients hospitalized in facilities that treat psychological disabilities must be allowed to wear their own clothing, use personal possessions, and...
Pharmacist's duties towards Medicaid recipients: To obtain, record and maintain pertinent patient information about the recipient; to undertake a review of the drugs previously dispensed to the recipient and to offer to discuss - Conn. Gen. Stat. § 20-620 Pharmacists must obtain and record the following information prior to or concurrent with dispensing a medication: (1) the individual’s name,...
Physical and psychiatric examinations - Conn. Gen. Stat. § 17a-545 Patients hospitalized in facilities that treat psychological disabilities must undergo a physical examination within 5 days of their admission and at...
Placement of patient in seclusion or mechanical restraint. Medication not to be used as substitute for habilitation - Conn. Gen. Stat. § 17a-544 Patients may only be involuntarily secluded or in mechanically restrained if they pose an “imminent physical danger” to themselves or...
Powers of ombudsman and representatives. Access to records, facilities and residents. Penalty for wilful interference with representatives of office. Confidentiality. Assistance from outside persons or entities - Conn. Gen. Stat. § 17b-410 The Long-Term Care Ombudsman and their representatives must have: “Access to long-term care facilities and residents.” “...
Prescriptions: Pharmacy to assign serial number and maintain records. Transfer of records to another pharmacy - Conn. Gen. Stat. § 20-615 Pharmacies must assign a serial number to each filled prescription and maintain records of all written, oral, and electronic prescriptions for a...
Record schedule under the public health and well-being regulations - CONN. AGENCIES REGS. § 19a-14-42 A health care provider must retain medical records for 7 years from the last date of treatment or, upon the date of the patient, for 3 years. 
Short-term hospitals, Children’s General - CONN. AGENCIES REGS § 19-13-D4a Children hospital buildings should be of sound construction and provide adequate accommodations for patients. The hospital should be in good repair...
Short-term hospitals, general and special - CONN. AGENCIES REGS § 19-13-D3 Short-term hospital buildings should be of sound construction and provide adequate accommodations for patients. The hospital should be in good repair...
Transcription and execution of verbal medication orders - Conn. Gen. Stat. § 19a-509d Pharmacists must document verbal medication orders in a patient’s chart immediately upon receiving such order from an “authorized...
Use of E-codes by hospitals, outpatient surgical facilities and outpatient clinics - Conn. Gen. Stat. § 19a-490e Short-term general hospitals, out-patient surgical facilities and outpatient clinics must include E-codes in the medical records of trauma patients...
Visitors. Restrictions on mail, telephone and visitor privileges, when allowed - Conn. Gen. Stat. § 17a-547 Patients hospitalized in facilities that treat psychological disabilities must be allowed to receive visitors in designated areas during facility...