10A N.C. Admin. Code 13B .3903 - PRESERVATION OF MEDICAL RECORDS
(a) The
manager of the medical records service shall maintain medical records that were
created when the patient was an adult, whether original, computer media, or
digital archived for 11 years following the discharge of an adult
patient.
(b) The manager of medical
records shall maintain medical records that were created when the patient was a
minor, whether original, computer media, or digital archived, until the
patient's 30th birthday. If a minor patient is readmitted as an adult, the
manager of the medical records shall maintain medical records according to
Paragraph (a) of this Rule.
(c) If
a hospital discontinues operation, its management shall make known to the
Division where its records are stored. Records shall be stored in a business
offering retrieval services for 11 years after the closure date or according to
Paragraph (b) of this Rule if the patient was a minor.
(d) The manager of medical records may
authorize the digital archiving of medical records. Digital archiving may be
done on or off the premises. If done off the premises, the facility shall
provide for the confidentiality and safekeeping of the records. The original of
digital archived medical records shall not be destroyed until the medical
records department has had an opportunity to review the digital record for
content.
(e) Nothing in this
Section shall be construed to prohibit the use of automation in the medical
records service, provided that all of the provisions in this Rule are met and
the information is readily available for use in patient care.
(f) Only personnel authorized by State laws
and the Health Insurance Portability and Accountability Act (HIPAA) found in 42
CFR 482, which is incorporated by reference including subsequent amendments and
editions, shall have access to medical records. This regulation may be obtained
free of charge at https://www.govinfo.gov/help/cfr.
Where the written authorization of a patient is required for the release or
disclosure of health information, the written authorization of the patient or
authorized representative shall be maintained in the original record as
authority for the release or disclosure.
(g) Medical records are the property of the
hospital, and shall remain the property of the hospital, except through a court
order. Copies shall be made available for authorized purposes such as insurance
claims and physician review.
Notes
Eff. January 1, 1996;
Amended Eff. July 1, 2009.
Eff. January 1, 1996;
Amended Eff. July 1, 2009.
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