105. Mass. Code Regs. 140.302. - Patient Records

Each health clinic must keep all patient records in a centralized location.  Each patient must have his or her own record with two forms of unique identification.  Each record must contain the following information:

1. Patient’s name, date of birth, sex, address, phone number, and responsible party;
2. Date of each visit;
3. Medical or dental history;
4. Diagnostic observations and evaluations;
5. Medication or treatment orders;
6. Lab, diagnostic or radiology reports;
7. Progress notes;
8. Reports of consultations;
9. Social service reports;
10. Referrals to other agencies;
11. Documentation of informed consent;
12. Discharge summary

Health clinics must maintain patient medical records for 20 years after final discharge or treatment of the patient.  Medical records can be in any format, but handwritten or typed records that have been converted into an electronic format can be destroyed before the 20 year period.  The way the records are destroyed must preserve the confidentiality of the records.  The clinic must give 30 days’ notice to the patient to inform him or her that the medical record will be destroyed.  

Patients have the right to inspect and copy their medical records upon written request.  The clinic may charge a fee associated with copying.  The clinic must give the patient written notice on its policy for inspection and copying of medical records.