The Right Way To Maintain Records

Patient records are broadly defined by the California Health & Safety Code as “records in any form, including electronic, in the custody of a health care provider that contains a patient’s health history, diagnosis or treatment that was or will be provided to the patient.”  The medical record includes physician progress notes, nurses /medical assistant notes, laboratory and test reports, medication lists and x-ray films, ekg tapes, pictures or videos.

The electronic health record (EHR) is an official record of digitized health information.  The term Electronic Medical Record (EMR) is often used interchangeably.  If patient’s medical data is shared with other facilities, locations, caregivers and/or billers, the term Electronic Health Record is more accurate.  A personal health record (PH) is a tool created and used by the patient to share previous and current health information.

California courts have ruled that billing records and records prepared by other health facilities and physicians are also part of the medical record.

Paper medical records should always be stored in a secure, safe and dry location.  If paper records are not stored at the practice, the practice should use reputable commercial document storage or a secure public storage facility.  Electronic records will remain on servers at the office or remote facility.

The medical record maintained should be all records that show the clinical care provided to the patient.  Records from other providers or hospitals should also be retained for the length of time outlined in the practice medical record retention policy, especially if these records were used in clinical decision making.

In California, because of the statute of limitations, medical practices are advised to maintain the medical records for at least 10 years after the patient’s last visit.  It additionally recommends to its members that minor patient medical records should be retained for at least one year after they turn 18.

A patient who requests his or her medical records be transferred to another physician, should do so in writing.  Only a deceased patient's named beneficiary or executor may request records. However, records may be requested and obtained by law enforcement or government agencies, when the cause of death is under investigation.

California law provides that patients have the right to examine and obtain either copies or a detailed summary of their medical records.  The HIPAA Privacy Rule prohibits physicians from substituting a summary unless the patient consents.  Furthermore, there are no allowances for withholding records until bills are paid.  The Health & Safety Code states that any physician who withholds patient records because of unpaid bills “is guilty of unprofessional conduct”.  Additionally, patients may request that information be deleted from the record.  Information should not be deleted from the record.  Health & Safety Code section 12311 states that an adult patient has the right to provide to the healthcare provider a written addendum that they believe to be incorrect.  Corrections in paper charts should be addressed by accepted documentation standards include a current date, a line marked through the erroneous entry and initials of the person making the entry.   Electronic Health Records (EHR) must be similarly corrected in a manner that retains the original entry while documenting the date, author and content of correction.

The guidelines from the California Medical Association indicate that the physician has 15 days to comply with a written request and may charge 25 cents/page plus a reasonable clerical fee.

Physicians who are retiring, leaving or closing a practice should arrange for records to be stored in a secure facility.  If the physician leaves a group practice, the group retains the medical records; patients who wish to follow that physician should request that a copy be sent to the new office.  The law requires that when a practice closes, someone is designated to respond to subpoenas and patient requests.

A practice may choose to destroy medical records after the retention time frame as passed.  California law requires that medical records destroyed by shredding, erasing or modifying make personal information unreadable and indecipherable. 

 Paula Paulson is a senior risk management specialist with the Cooperative of American Physicians. This is the last in a series.