Current through Register 2021 Notice Reg. No. 52, December 24, 2021
(a) Records shall be kept on all patients
admitted or accepted for treatment. All required records, either as originals
or accurate reproductions of the contents of such originals, shall be
maintained in such form as to be legible and readily available upon the request
of: the attending physician or psychologist; the hospital or its medical staff
or any authorized officer, agent or employee of either; authorized
representatives of the Department; or any other person authorized by law to
make such a request.
medical record, including X-ray film, is the property of the hospital and is
maintained for the benefit of the patient, the medical staff and the hospital.
The hospital shall safeguard the information in the record against loss,
defacement, tampering or use by unauthorized persons.
(c) Patient records including X-ray film or
reproductions thereof shall be preserved safely for a minimum of seven years
following discharge of the patient, except that the records of unemancipated
minors shall be kept at least one year after such minor has reached the age of
18 years and, in any case, not less than seven years.
(d) If a hospital ceases operation, the
Department shall be informed within 48 hours of the arrangements made for safe
preservation of patient records as above required.
If ownership of a licensed hospital
changes, both the previous licensee and the new licensee shall, prior to the
change of ownership, provide the Department with written documentation that:
(1) The new licensee will have custody of the
patients' records upon transfer of the hospital, and that the records are
available to both the new and former licensee and other authorized persons;
(2) Arrangements have been made
for the safe preservation of patient records, as required above, and that the
records are available to both the new and former licensees and other authorized
records shall be filed in an easily accessible manner in the hospital or in an
approved medical record storage facility off the hospital premises.
Medical records shall be completed
promptly and authenticated or signed by a licensed healthcare practitioner
acting within the scope of his or her professional licensure within two weeks
following the patient's discharge. Medical records may be authenticated by a
signature stamp or computer key, in lieu of a signature by a licensed
healthcare practitioner acting within the scope of his or her professional
licensure, only when that licensed healthcare practitioner acting within the
scope of his or her professional licensure has placed a signed statement in the
hospital administrative office to the effect that he/she is the only person
(1) Has possession of the stamp or
(2) Will use the stamp or
(h) Medical records
shall be indexed according to patient, diagnoses and attending member of the
(i) By July 1, 1976
a unit medical record system shall be established and implemented with
inpatient, outpatient and emergency room records combined.
(j) The medical record shall be closed and a
new record initiated when a patient is transferred to a different level of care
within a hospital which has a distinct part skilled nursing or intermediate