10A N.C. Admin. Code 13D.2402 - Nursing Home Preservation of Medical Redcords

Medical records are the property of the facility, and they shall not be removed from the facility except through a court order. Copies shall be made available for authorized purposes such as insurance claims and physician review.

Medical records, whether original, computer media or microfilm, must be kept on file for a minimum of five years following the discharge of an adult patient. If the patient is a minor when discharged from the nursing facility, records shall be kept on file until his or her 19th birthday and, then, for five years.

If a facility discontinues operation, the licensee shall make known to the Division of Health Service Regulation where its records are stored, which must be a business offering retrieval services for at least 11 years after the closure date.

The manager of medical records may authorize the microfilming of medical records, to be done on or off the premises. If done off the premises, records must be kept confidential and the facility mut ensure the originals are not destroyed until the manager of medical records has had an opportunity to review the processed film for content.

Nothing prohibits the use of automated medical records, provided all of the provisions in this rule are met and the medical record is readily available for use in patient care.

All medical records are confidential and only authorized personnel are permitted access. Before medical information is released outside the facility, the records must contain signed authorization forms concerning approval or disapproval of release. Upon inspection, the Department shall be notified of the name and record number of any patient who has denied medical record access to the Department.