Ownership - 28 Pa. Code § 563.10

Ambulatory surgical facilities must maintain a separate medical record for each patient that includes the following information: 28 Pa. Code Chapter 563, “Form and content of record” 28 Pa. Code § 563.12

•         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. 28 Pa. Code Chapter 563, “Ownership” 28 Pa. Code §563.10  Records are confidential, and may only be released upon written authorization of the patient or to authorized personnel. 28 Pa. Code Chapter 563, “Confidentiality of medical records” 28 Pa. Code § 563.9  Patients may access their records, and may be charged a reasonable fee for the cost of copying the records. 28 Pa. Code Chapter 563, “Patient access” 28 Pa. Code § 563.11  Records must be stored to prevent loss, damage or unauthorized access. 28 Pa. Code Chapter 563, “Storage of medical records” 28 Pa. Code § 563.5  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. 28 Pa. Code Chapter 563, “Preservation of medical records” 28 Pa. Code § 563.6