Patient medical records - 28 Pa. Code § 115.31

All hospitals must maintain patient records in accordance with the following provisions:

•         A medical record must be maintained for every inpatient, outpatient and patient treated or examined in the emergency unit; the record must contain data from all episodes of care and treatment of the patient, and the unit record system must be used whenever feasible.1
•         The record must contain information to identify the patient, to justify the diagnosis and treatment, and to document the results accurately; the record must include the findings of any pathological or clinical laboratory examinations, radiology examinations, medical and surgical treatment, and other diagnostic or therapeutic procedures.2
•         All records are confidential, and only authorized persons may access them.3 Access to such records will be provided under the following circumstances:

o       To the medical records committee for review of completeness and to ensure that the recorded information is sufficient for medical care evaluation;4

o       To patients, who may obtain a copy of such records for a reasonable fee.5

•         Medical records must be stored to protect against loss, damage and unauthorized access.6
•         Records must be kept on file for seven years after discharge; if the patient is a minor, the records must be kept for seven years after his majority.7   
•         The following information must specifically be recorded in the record, if provided:

o       Social work services;8

o       Authenticated reports of radiology interpretations, and of consultation, therapy, and radiotherapy summaries;9

o       Reports of nuclear medicine interpretations, consultations, and therapy showing the identity, date and amount of radiopharmaceutical used, as well as any specific patient preparation performed;10

o       Inpatient rehabilitation therapy orders, procedures and treatments, including notations by the responsible therapist reflecting repeated evaluations of the patient’s progress;11 and

o       Any dental services.12