Under Massachusetts law, a physician must maintain adequate records for each patient, and retain the record for at least seven years from the date of the last encounter with the patient or until the patient reaches the age of nine (if more than seven years).1  Hospitals must also keep records of the cases treated, either in handwritten, printed, typed or electronic digital media.  The hospital can destroy the records only after the retention period of 20 years has elapsed and after notifying the Department of Public Health that the records are being destroyed.  Hospitals must inform patients of the records’ termination policy. 2  Massachusetts also imposes very specific recordkeeping requirements on hospitals.  Notably, the state requires all acute care hospitals to record each patient’s primary spoken language and race/ethnicity.3

Massachusetts also sets forth requirements for the maintenance of medical records by heath clinics.  Health clinics must maintain patient medical records for 20 years after final discharge or treatment of the patient.  Medical records can be in any format, but handwritten or typed records that have been converted into an electronic format can be destroyed before the 20 year period.  When the records are destroyed, they must preserve patient confidentiality.  The clinic must give 30 days’ notice to the patient to inform him or her that the medical record will be destroyed.4  Massachusetts law also expressly states that nursing homes and community health clinics must satisfy the minimum rules of recordkeeping set forth by the Department of Health.5

Massachusetts also has regulations that deal specifically with the maintenance of medical records for MassHealth (the state’s Medicaid program).  All providers (defined as “individual, group, facility, agency, institution, organization, or business that furnishes medical services and participates in MassHealth “) must keep documentation of the services provided under MassHealth, including medical records, to disclose the extent of and medical necessity of the services provided.  Providers must also maintain patient account records, which completely document charges, indicate debits and credits, and show the amounts billed and paid.6  Providers must keep all records for at least six years from the date of medical service for which payment claims are made.7

Massachusetts law provides that physicians must provide all patients the opportunity to inspect his or her record and have a copy of the record if the patient so requests.8  This requirement also applies to all licensed health care facilities, including hospitals and nursing homes, which are required to make medical records available to a patient or his or her authorized representative for inspection and copying upon written request.9  This right to inspect and copy and the retention policy must be provided to the patient by the hospital.  However, the law authorizes the hospital to charge a reasonable copying fee to cover administrative costs.10  The hospital or clinic cannot charge a fee to a patient who requests a copy of his or her medical record for the purpose of supporting a claim or appeal under the Social Security Act or any other federal or state financial needs based assistance program.11  Massachusetts extends the right for a patient to have access to his or her personal medical information to data held by insurance companies.12  Insurers must give consumers access to medical information in the insurer’s possession.13  Massachusetts also gives patients the right to receive an itemized list of charges from hospitals upon written request.  This right is protected to strongly that the failure of a hospital to provide the itemized bill within ten days of the request leads to the dissolution of the amount owed to the hospital.14  

Under Massachusetts law, access to medical records is also permitted by local public health departments and the Department of Health in order to monitor or prevent the spread of disease.  School officials may also be granted access to a child’s immunization records held by a health care provider without the prior authorization of the parents if parents are unable to provide these records.15  Similarly, the law allows certain disease specific registries access to patient medical records for verification purposes.16