Maine law requires that hospitals keep patient records for a period of seven years.  If the patient is a minor, the records must be retained for at least six years after the minor reaches the age of majority.  However, the law also requires that before a general or specialized hospital destroys any patient x-rays or other images of a patient, the hospital must give prior notice to the patient, either directly or through a newspaper with broad circulation.1  The law also states what information must be contained in a patient’s hospital medical record.  It also specifies that the information contained in the medical record must be authenticated, pertinent timely, and must be adequate to sufficiently identify the patient.  Items such as discharge instructions, consultations, progress notes, initial plans of care and provisional diagnoses must be included in the record.  Additionally, each medical record must document whether the patient has executed an advanced directive, such as a living will or medical power of attorney.2  In addition, the Maine law requires the hospital record department to have a quality assurance plan in place to continually monitor and evaluate the services that are provided, and implement improvements if needed.  A backup plan must exist that permits the retrieval of records by appropriately trained personnel when it is not possible to staff the records department 24 hours a day, seven days a week.  Finally, the hospital must use a coding system for diseases and procedures in order to maintain an indexing system that allows for easy retrieval of statistical and billing information.3

The state of Maine also requires Ambulatory Surgical Facilities to keep complete, comprehensive and accurate medical records to ensure proper patient care.  Each patient must have his or her own record, which includes patient identification, significant medical history and results of physical examinations, any allergies and drug reactions, discharge diagnoses, documentation of informed patient consent, documentation of anesthesia administration, and operative and pre-operative studies.4

Skilled nursing facilities are also required by law to maintain clinical records on each patient.  The records must include all current clinical information pertaining to a resident’s stay, non-clinical, identifying information, and individual administrative records of each patient on hand at the facility.  Each resident must also have a separate folder which may include resident rights acknowledgments, contracts with the resident, statements of who is responsible for personal needs monies, and records of personal needs monies, including receipts, bank books, or statements and any relevant documentation.  Nursing facilities are legally required to keep all clinical medical records for five years from the date of discharge.  If the patient is a minor, the facility must keep the clinical records for three years after a resident reaches legal age.  All patient records must be available at the nurses’ station, and be kept in the facility at all times, and may be in either paper or electronic format.5  Nursing facilities are also required to keep referral forms in the patient’s medical record if the patient is transferred to another facility.6

Similar requirements are also imposed on assisted living facilities.  For each individual that receives assisted living services, the program must keep a record that includes identifying information of the consumer and his or her emergency contact, a functional assessment of the consumer, a service plan, an authorization for release of information and documented proof of legal representation.7

End stage renal disease facilities are also required to keep, at a minimum, individual patient care clinical records, personnel files for all staff, records of water system maintenance and quality control, and records related to reuse procedures.  All records must be kept for seven years from the date of a patient’s discharge.8

Maine law also requires home health care services to maintain an identifiable clinical record.  The record must contain such information as appropriate identifying information, a medication list, a care plan, periodic assessments of the patient, and summary notes of the care provided. 9

Hospice programs are also required by Maine law to maintain records of care plans of interdisciplinary teams, progress notes regarding the families receiving services, all receipts and expenditures, a discharge summary for every patient (a copy of which must be provided to the primary physician), and minutes of all governing body meetings.  All clinical and business records must be kept by the program for five years from the date of patient discharge.10

The state requires consumer records to be maintained for each individual who attends an adult day service program.  Such records must be kept at the program site or central office for a minimum of five years after the consumer leaves the program.11  

Maine also has a number of laws in place guaranteeing patients access to their medical records and other medical information.  For example, patients are entitled to copies of their medical records from their physicians upon submitting a written request and the payment of a small fee to cover copying and administrative costs.12  Similarly, hospitals are required to provide patients with a copy of their medical record as well as give patients a copy of an itemized bill upon written request.13  Hospitals are also required to provide patients with the average charge for inpatient or outpatient service upon request.14  Nursing facilities must give patients access to their records within 24 hours of a request.15  The state also requires insurers to provide patients access to recorded personal information, upon written request.  The patient or consumer must also have the opportunity to inspect or copy the information, and have a chance to amend or delete the information held by the insurer.16