Cal. Code Regs. Tit. 22, § 72543 - Patients' Health Records
(a)
Records shall be permanent, either typewritten or legibly written in ink, be
capable of being photocopied and shall be kept on all patients admitted or
accepted for care. All health records of discharged patients shall be completed
and filed within 30 days after discharge date and such records shall be kept
for a minimum of 7 years, except for minors whose records shall be kept at
least until 1 year after the minor has reached the age of 18 years, but in no
case less than 7 years. All exposed X-ray film shall be retained for seven
years. All required records, either originals or accurate reproductions
thereof, shall be maintained in such form as to be legible and readily
available upon the request of the attending licensed healthcare practitioner
acting within the scope of his or her professional licensure, the facility
staff or any authorized officer, agent, or employee of either, or any other
person authorized by law to make such request.
(b) Information contained in the health
records shall be confidential and shall be disclosed only to authorized persons
in accordance with federal, state and local laws.
(c) If a facility ceases operation, the
Department shall be informed within three business days by the licensee of the
arrangements made for the safe preservation of the patients' health
records.
(d) The Department shall
be informed within three business days, in writing, whenever patient health
records are defaced or destroyed before termination of the required retention
period.
(e) If the ownership of the
facility changes, both the licensee and the applicant for the new license
shall, prior to the change of ownership, provide the Department with written
documentation stating:
(1) That the new
licensee shall have custody of the patients' health records and that these
records or copies shall be available to the former licensee, the new licensee
and other authorized persons; or
(2) That other arrangements have been made by
the licensee for the safe preservation and the location of the patients' health
records, and that they are available to both the new and former licensees and
other authorized persons; or
(3)
The reason for the unavailability of such records.
(f) Patients' health records shall be current
and kept in detail consistent with good medical and professional practice based
on the service provided to each patient. Such records shall be filed and
maintained in accordance with these requirements and shall be available for
review by the Department. All entries in the health record shall be
authenticated with the date, name, and title of the persons making the
entry.
(g) All current clinical
information pertaining to a patient's stay shall be centralized in the
patient's health record.
(h)
Patient health records shall be filed in an accessible manner in the facility
or in health record storage. Storage of records shall provide for prompt
retrieval when needed for continuity of care. Health records can be stored off
the facility premises only with the prior approval of the Department.
(i) The patient health record shall not be
removed from the facility, except for storage after the patient is discharged,
unless expressly and specifically authorized by the Department.
Notes
Note: Authority cited: Sections 1275, 100275 and 131200, Health and Safety Code. Reference: Sections 1276, 1316.5, 131050, 131051 and 131052, Health and Safety Code.
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