§ 25.213. Medical records.
(a) A medical record shall be maintained for each patient, identifying the patient, the person making the entry, the date of each contact, pertinent clinical information, diagnoses, findings, laboratory results and other diagnostic, corrective or therapeutic procedures, including prescription drug orders, arising out of the licensee’s care of the patient.
(b) A patient’s medical record shall be retained for at least 7 years from the last entry. In addition, for minors, the medical record shall be retained until 2 years after the patient’s 18th birthday or 7 years from the last entry, whichever is later. Storage may be off-premises.
(c) Medical records shall be kept confidential, unless disclosure is required for bona fide treatment, with the patient’s written consent, except as follows:
(1) Upon receipt of a court order for the production of documents.
(2) Upon lawful demand by auditors for public or private third-party payers which have contracted to reimburse the licensee for services provided to the patient.
(3) To defend against allegations of civil or criminal medical malpractice, if the licensee’s treatment of the patient has been placed at issue by the complaining party, and only to the extent necessary to controvert factual allegations in the complaint.
(4) To comply with other relevant State or Federal health care laws.
(d) The licensee shall provide a patient with a complete copy of the patient’s medical record, within a reasonable time of the request of the patient or an authorized representative. Reasonable charges for copying may be made.
Authority The provisions of this § 25.213 issued under section 16 of the Osteopathic Medical Practice Act (63 P. S. § 271.16); and section 902(b) of the Health Care Services Malpractice Act (40 P. S. § 1301.902(b)).
Source The provisions of this § 25.213 adopted January 10, 1992, effective January 11, 1992, 22 Pa.B. 209.
Cross References This section cited in 34 Pa. Code § 501.5 (relating to exemptions); and 49 Pa. Code § 25.415 (relating to confidentiality—waived).
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