Cal. Code Regs. Tit. 22, § 74731 - Patients' Health Records Availability

(a) Each patient health record, either original or an accurate reproduction, shall be:

(1) Permanent, either typewritten or legibly written in ink, and be capable of being photocopied.

(2) Current and kept in sufficient detail to identify the patient's health status for health care providers.

(3) Be readily available for review upon request of the attending physician or other prescriber; any authorized employee, agent or officer of the agency; authorized representatives of the Department; or any other person authorized by law to make such a request.

(b) The agency shall safeguard the information in the record against loss, defacement, tampering or use by unauthorized persons.

(c) All health records of discharged patients shall be completed within 30 days after their discharge date.

(d) Health records of each discharged adult patient shall be kept for a minimum of seven years following discharge of the patient. The health record of a discharged minor shall be kept for at least one year after the minor has reached the age of 18 years and in all cases not less than seven years.

(e) The Department shall be informed immediately, in writing, whenever patient health records are defaced or destroyed before termination of the required retention period.

(f) If any agency ceases operation, the agency shall make arrangements to transfer the records to the new agency or make other arrangements for the safe preservation of the records. The Department shall be notified in writing of the location of the records.

(g) If the ownership of the agency changes, both the licensee and the applicant for the new license shall, prior to the change in ownership, provide the Department with written documentation that:

(1) The new licensee will have custody of the patient's health records upon transfer of the agency and the health records are available to both the new and former licensee and other authorized persons; or

(2) Other arrangements have been made for the safe preservation of patients' health records, and that the health records are available as set forth within this regulation.

(h) If the agency stores records in an off-site location, the following requirements shall apply:

(1) Timely accessibility of stored records on a 24 hour basis, seven days a week.

(2) Records are organized and systematically maintained.

(3) Protection of the clinical records from loss, destruction or unauthorized use.

(4) A current written agreement with the storage facility.

(5) Policies and procedures which address the retention, retrieval and security for off-site centralized storage of inactive patient records.

(i) If the agency utilizes computerized patient records, policies and procedures shall be established and implemented which address data security, privacy, and confidentiality in conformance with state law.

(1) The agency shall protect patients from unnecessary intrusion into their private lives by safeguarding the health information entrusted to them.

(2) The agency shall assure conformance with current acceptable professional standards and follow state laws that may be more prescriptive.

Notes

Cal. Code Regs. Tit. 22, § 74731

1. Amendment of section heading, section and NOTE filed 4-28-95 as an emergency; operative 4-28-95 (Register 95, No. 17). A Certificate of Compliance must be transmitted to OAL by 8-28-95 or emergency language will be repealed by operation of law on the following day.
2. Amendment of section heading, section and NOTE refiled 8-14-95 as an emergency; operative 8-14-95 (Register 95, No. 33). A Certificate of Compliance must be transmitted to OAL by 12-12-95 or emergency language will be repealed by operation of law on the following day.
3. Amendment of section heading, section and NOTE refiled 12-12-95 as an emergency; operative 12-12-95 (Register 95, No. 50). A Certificate of Compliance must be transmitted to OAL by 4-10-96 or emergency language will be repealed by operation of law on the following day.
4. Editorial correction of section heading and subsection (i)(2) (Register 96, No. 15).
5. Amendment of section heading, section and NOTE refiled 4-11-96 as an emergency; operative 4-11-96 (Register 96, No. 15). A Certificate of Compliance must be transmitted to OAL by 8-9-96 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 4-28-95 order transmitted to OAL 8-7-96 and disapproved 9-19-96 (Register 96, No. 38).
7. Amendment of section heading, section and NOTE filed 9-19-96 as an emergency; operative 9-19-96 (Register 96, No. 38). A Certificate of Compliance must be transmitted to OAL by 1-17-97 or emergency language will be repealed by operation of law on the following day.
8. Editorial correction of HISTORY 7 (Register 97, No. 3).
9. Amendment of section heading, section and NOTE refiled 1-16-97 as an emergency; operative 1-16-97 (Register 97, No. 3). A Certificate of Compliance must be transmitted to OAL by 5-16-97 or emergency language will be repealed by operation of law on the following day.
10. Amendment of section heading, section and NOTE refiled 5-15-97 as an emergency; operative 5-15-97 (Register 97, No. 20). A Certificate of Compliance must be transmitted to OAL by 9-12-97 or emergency language will be repealed by operation of law on the following day.
11. Editorial correction of subsection (g)(1) (Register 97, No. 41).
12. Certificate of Compliance as to 5-15-97 order, including amendment of section heading, subsection (i) and NOTE, transmitted to OAL 8-26-97 and filed 10-8-97 (Register 97, No. 41).

Note: Authority cited: Sections 1734 and 100275, Health and Safety Code. Reference: Sections 1727.5(e), 1734, 123145(a) and 123149, Health and Safety Code.

1. Amendment of section heading, section and Note filed 4-28-95 as an emergency; operative 4-28-95 (Register 95, No. 17). A Certificate of Compliance must be transmitted to OAL by 8-28-95 or emergency language will be repealed by operation of law on the following day.
2. Amendment of section heading, section and Note refiled 8-14-95 as an emergency; operative 8-14-95 (Register 95, No. 33). A Certificate of Compliance must be transmitted to OAL by 12-12-95 or emergency language will be repealed by operation of law on the following day.
3. Amendment of section heading, section and Note refiled 12-12-95 as an emergency; operative 12-12-95 (Register 95, No. 50). A Certificate of Compliance must be transmitted to OAL by 4-10-96 or emergency language will be repealed by operation of law on the following day.
4. Editorial correction of section heading and subsection (i)(2) (Register 96, No. 15).
5. Amendment of section heading, section and Note refiled 4-11-96 as an emergency; operative 4-11-96 (Register 96, No. 15). A Certificate of Compliance must be transmitted to OAL by 8-9-96 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 4-28-95 order transmitted to OAL 8-7-96 and disapproved 9-19-96 (Register 96, No. 38).
7. Amendment of section heading, section and Note filed 9-19-96 as an emergency; operative 9-19-96 (Register 96, No. 38). A Certificate of Compliance must be transmitted to OAL by 1-17-97 or emergency language will be repealed by operation of law on the following day.
8. Editorial correction of History 7 (Register 97, No. 3).
9. Amendment of section heading, section and Note refiled 1-16-97 as an emergency; operative 1-16-97 (Register 97, No. 3). A Certificate of Compliance must be transmitted to OAL by 5-16-97 or emergency language will be repealed by operation of law on the following day.
10. Amendment of section heading, section and Note refiled 5-15-97 as an emergency; operative 5-15-97 (Register 97, No. 20). A Certificate of Compliance must be transmitted to OAL by 9-12-97 or emergency language will be repealed by operation of law on the following day.
11. Editorial correction of subsection (g)(1) (Register 97, No. 41).
12. Certificate of Compliance as to 5-15-97 order, including amendment of section heading, subsection (i) and Note, transmitted to OAL 8-26-97 and filed 10-8-97 (Register 97, No. 41).