Medical Records Requirements in Hospitals – N.Y. Comp. Codes R. & Regs. tit. 10 § 405.10

Hospitals must have a department that has administrative responsibility for medical records. An accurate, clear, and comprehensive medical record must be maintained for every person evaluated or treated as an inpatient, ambulatory patient, emergency patient or outpatient of the hospital.

Medical records must be legibly and accurately written, complete, properly filed, retained and accessible in a manner that does not compromise the security and confidentiality of the records.  Hospitals must ensure that all medical records are completed within 30 days following discharge.  The records should be retained in their original or legally produced form for a period of at least six years from the date of discharge, or three years after the patient’s age of majority, or at least six years after death.

Hospitals must have a system of coding and indexing for medical records that allows for timely retrieval by diagnosis and procedure in order to support quality assurance studies.

Each hospital must ensure the confidentiality of the patient records.  The original records may be released only to hospital staff involved in treating the patient and individuals permitted by Federal and State laws.  

The medical record must contain information to justify the admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services.  Additionally, all records must document, as appropriate, at least the following:

• Evidence of a physical examination, including a health history, performed no more than thirty days prior to admission or within 24 hours after admission and a statement of the conclusion or impressions drawn;
• Admitting diagnosis;
• Results of all consultative evaluations of the patient and findings by clinical and other staff involved in the care of the patient;
• Documentation of all complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia;
• Properly executed consent forms for procedures and treatments;
• All practitioners' diagnostic and therapeutic orders, nursing documentation and care plans, reports of treatment, medication records, radiology, and laboratory reports, vital signs and other information necessary to monitor the patient's condition;
• Discharge summary with outcome of hospitalization, disposition of case and provisions for follow-up care; and
• Final diagnosis.