Record keeping requirements under the health regulations - D.C. MUN. REGS. tit. 22-B § 2030

A hospital must maintain records for each patient and retain them for 10 years after discharge or, in the case of a minor, 3 years after the minor patient reaches 18 years of age. Records may be maintained in electronic format, as long as the record is accessible. The record must contain information sufficient to identify the patient and justify the diagnosis and treatment.
 
Each record must contain:
·         Patient identification information
·         Chief complaint
·         Present illness
·         History and physical examination
·         Admitting diagnosis
·         All pathology/laboratory and radiology reports
·         Properly executed informed consent forms
·         Consultation reports
·         Medical practitioner orders
·         Documentation of all treatment
·         Tissue report
·         Progress notes
·         Discharge summary and final diagnosis
·         Autopsy findings; and
·         Advanced directives
 
 
Medical record entries must be dated, legible, and authenticated via signature, initials, or computer entry.
Records should be completed within 30 days of discharge. Medical records are confidential, and should only be released with consent of the patient or as permitted by law.
A hospital shall maintain a permanent master patient index, which includes names and identification numbers of each patient, dates of admission and discharge, name of admitting physician, and disposition. A hospital must also maintain records of reports involving abuse, neglect, misappropriation of property or exploitation.
Medical records may only be destroyed via shredding, incineration, electronic deletion, or another equally effective protective measure in order to preserve patient confidentiality.