Cal. Code Regs. Tit. 22, § 70751 - Medical Record Availability
(a)
Records shall be kept on all patients admitted or accepted for treatment. All
required patient health 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:
(1) The admitting licensed healthcare
practitioner acting within the scope of his or her professional
licensure.
(2) The nonphysician
granted privileges pursuant to Section
70706.1.
(3) The hospital or its medical staff or any
authorized officer, agent or employee of either.
(4) Authorized representatives of the
Department.
(5) Any other person
authorized by law to make such a request.
(b) The medical record, including X-ray
films, 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 films or reproduction 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.
(e) 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;
or
(2) Arrangements have been made
for the safe preservation of patient records, as above required, and that the
records are available to both the new and former licensees and other authorized
persons.
(f) Medical
records shall be filed in an easily accessible manner in the hospital or in an
approved medical record storage facility off the hospital premises.
(g) 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 offices to the effect that he/she is the only
person who:
(1) Has possession of the stamp or
key.
(2) Will use the stamp or
key.
(h) Medical records
shall be indexed according to patient, disease, operation and licensed
healthcare practitioner acting within the scope of his or her professional
licensure.
(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
care service.
Notes
2. Amendment of subsections (a)(1), (g) and (h) and NOTE filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).
Note: Authority cited: Sections 1275, 100275 and 131200, Health and Safety Code. Reference: Sections 1276, 1316.5, 131050, 131051 and 131052, Health and Safety Code.
2. Amendment of subsections (a)(1), (g) and (h) and Note filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).
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