49 Pa. Code § 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.
Notes
The provisions of this § 25.213 issued under
section 16 of the Osteopathic Medical Practice
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