Form and content of record - 28 Pa. Code § 563.12

Ambulatory surgical facilities must maintain a separate medical record for each patient that includes the following information:1

•         Patient identification;
•         Pertinent medical history and results of physical examination;
•         Preoperative diagnostic studies—entered before surgery—if performed;
•         The presence or absence of allergies and untoward drug reactions recorded in a prominent and uniform location in all patient charts on a current basis;
•         Documentation of properly executed, informed patient consent;
•         Entries related to anesthesia administration;
•         Findings and techniques of the operation, including a pathologist report on tissue removed during surgery;
•         Notes by authorized staff members and individuals who have been granted clinical privileges, nurses’ notes and entries by other professional personnel;
•         Written and verbal disposition recommendations and instructions given to the patient;
•         Significant medical advice given to a patient by telephone; and
•         Discharge summary including discharge diagnosis.

Medical records are the property of the facility and may not be removed from the premises except for court purposes; copies may be made available for authorized purposes.2  Records are confidential, and may only be released upon written authorization of the patient or to authorized personnel.3  Patients may access their records, and may be charged a reasonable fee for the cost of copying the records.4  Records must be stored to prevent loss, damage or unauthorized access.5  The facility must retain medical records for seven years after discharge of the patient; if the patient is a minority, records must be kept on file until majority and then for seven years.6