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Patient medical records under the general records schedule for public hospitals and health care providers - GENERAL RECORDS SCHEDULE - GS4 PUBLIC HEALTH CARE FACILITIES AND PROVIDERS

Link to the law
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Public hospitals must retain patient medical records for seven years after the last entry. The record must contain:
·         Identification data
·         Chief complaint
·         Present illness
·         Medical history
·         Physician examination report
·         Diagnosis
·         Laboratory, testing, and consultation reports
·         Documentation of informed consent
·         Medication and dosage administered
·         Progress notes
·         Discharge summary
·         Autopsy findings

Current as of January 2016