MONT. ADMIN. R. 37.106.402 - Minimum standards for a hospital: medical records under the public health and human services regulations

A hospital must retain patient records for 10 years from a patient’s discharge or death. If the patient is a minor, the hospital must retain the record for 10 years after the patient reaches the age of 18, or dies if earlier. The medical record may be abridged after 10 years; the core medical record or microfilmed medical record should be maintained permanently but must be maintained for the times specified above. A core medical record contains the following:
·         Patient identification data
·         Medical history
·         Physical examination report
·         Consultation reports
·         Operation report
·         Pathology report
·         Discharge summary
·         Autopsy findings
 
The hospital must develop an obstetrical record for each maternity patient.
 
The hospital must develop a record for each newborn including the following:
·         Observations
·         Delivery room care
·         Physical examination
·         Temperature
·         Weight
·         Time of first urination
·         Stool information
·         Type of feeding
·         Name of person to whom newborn is to be released
 
 
 
Hospitals may retain records for periods longer than described. Diagnostic imaging film and electrodiagnostic tracings must be retained for 5 years.