physician shall maintain medical records for patients which accurately, legibly
and completely reflect the evaluation and treatment of the patient. The
components of the records are not required to be maintained at a single
location. Entries in the medical record shall be made in a timely
(b) The medical record
shall contain information sufficient to clearly identify the patient, the
person making the entry if the person is not the physician-such as a physician
assistant or a certified registered nurse practitioner-the date of the medical
record entry and patient complaints and symptoms.
(c) Clinical information pertaining to the
patient which has been accumulated by the physician, either by himself or
through his agents, shall be incorporated in the patient's medical
(d) The medical record
shall also include diagnoses, the findings and results of pathologic or
clinical laboratory examination, radiology examination, medical and surgical
treatment and other diagnostic, corrective or therapeutic procedures.
(e) A patient's medical record shall be
retained by a physician for at least 7 years from the date of the last medical
service for which a medical record entry is required. The medical record for a
minor patient shall be retained until 1 year after the minor patient reaches
majority, even if this means that the physician retains the record for a period
of more than 7 years.
components of a patient's medical record, which are prepared by a physician or
his agent and which are retained by a health care facility regulated by the
Federal government, or by the Department of Health or the Department of Public
Welfare are considered to be a part of the patient's medical record which is
required to be maintained by a physician, but are otherwise exempt from the
requirements in subsections (a)-(e). These components of a patient's medical
record shall contain information required by applicable Federal regulations, or
by 28 Pa. Code (relating to health and safety) or 55 Pa. Code (relating to
public welfare)-see for example, Department of Health regulations at 28 Pa.
§ 115.31-115.34 (relating to policies and procedures for
patient medical records)-and health care facility and medical staff