Patient Record Requirements for Community Health Centers – Cal. Code Regs. tit. 22 § 80070

A separate, current and complete record must be maintained for each patient/client admitted into a community health center.  The patient’s record must be retained for at least three years after termination of service to the patient.  Each record must contain the patient’s name, birth date, sex, date of admission, emergency contact/authorized representative, name and address of relevant health care provider, medical assessment, a signed copy of the admissions agreement, and medications taken.  The community health center must ensure that all information remains confidential.  However, all records must be made available to the state licensing agency for review.