Clinical records - 28 Pa. Code § 211.5

Long term care facility’s clinical records must conform to the following requirements:

• Information contained in the resident’s record is privileged and confidential;
• Release of information from the resident’s record is prohibited except in the following circumstances:
  • To representatives of the department of aging ombudsman program;
  • On the written consent of the resident or his designated agent; and
  • To authorized representatives of the state and federal government conducting their official duties.
• Records must be retained for seven years following a resident’s discharge or death; and
• Records must include the following information:
  • Physician’s orders, observation and progress notes, nurses’ notes, medical and nursing history and physical examination reports;
  • Identification information, admission data, a resident needs assessment, appropriate treatment plan and plan of care and services; and

Hospital diagnoses authentication, diagnostic and therapeutic orders, reports of treatment, clinical findings, medication records and discharge summary