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Medical Records Collection, Retention, and Access in Ohio

Ohio law governs the collection, retention and access of medical records across provider types and facilities.  As a condition of licensure, the following facilities and programs must maintain medical records for every patient for the designated time period.  Each health care facility1 must maintain records for six years from the date of discharge, documenting the patient’s needs and assessments and services rendered.2  The provider of a health care service3 must maintain records for five years from the date of discharge; such record must document the patient’s needs and assessments and services rendered.4  Each residential care facility must maintain records for seven years following the date of the resident’s discharge.5  Every nursing home must maintain records for seven years following the date of the resident’s discharge.6  Each freestanding or mobile diagnostic imaging center must maintain all records for six years from the date of service.7  Adult care facilities must maintain a record for two years after the resident is permanently transferred, discharged, or dies.8

Some providers are required to document certain elements about the patient in the patient’s medical record.  Health care facility records9 and ambulatory surgical facility records10 must document the name, address, date of birth, gender, and race or ethnicity of the patient.  Every nursing home record must document the patient’s name, age, sex, race/ethnicity, and religion.11    

Ohioans have the right to access their health care records. In order examine or obtain a copy of all or part of one’s medical record, a patient, his personal representative or an authorized person must submit such a request in writing to the provider; the provider must comply with the request unless disclosure would be medically contraindicated, in which case the provider will provide the record to a designated physician or chiropractor.  A patient, his personal representative or an authorized person may bring a civil action against any provider who fails to furnish a medical record to enforce the patient’s right of access to the record.12  Managed health care program members have the right to request and receive a copy of their medical records.13

All pharmacies must maintain a patient profile system, and the dispensing pharmacist will be responsible for ensuring that a reasonable effort has been made to obtain, document and maintain the patient’s data record and the patient’s drug therapy record for all of the prescriptions that were filled at the pharmacy within the last twelve months; the patient profile shall be maintained for at least one year from the date of the last entry in the profile record.14  All records relating to the practice of pharmacy, including prescription information entered into the record-keeping system, prospective drug utilization review, patient counseling and prescription information must be uniformly maintained for three years.15  A person having custody of or access to records relating to the practice of pharmacy, the administration of drugs, or any patient-specific drug transaction may disclose the contents of the records, or provide a copy of the records, to the patient for whom the prescription or medication order was issued.16

 

Footnotes

  • 1. Note: The definition of a health care facility (HCF) is located in Ohio Admin. Code 3701-83-01(I) “General definitions”.
  • 2. Ohio Admin. Code 3701-83-11
  • 3. Note: a health care service is defined in Ohio Admin. Code 3701-84-01(K) “General Definitions”.
  • 4. Ohio Admin. Code 3701-84-11
  • 5. Ohio Admin. Code 3701-17-67
  • 6. Ohio Admin. Code 3701-17-19
  • 7. Ohio Admin. Code 3701-83-54
  • 8. Ohio Admin. Code 5122-33-15
  • 9. Ohio Admin. Code 3701-83-23.3
  • 10. Ohio Admin. Code 3701-83-21
  • 11. Ohio Admin. Code 3701-17-19
  • 12. Ohio Rev. Code Ann. § 3701.74
  • 13. Ohio Admin. Code 5101:3-26-08.3
  • 14. Ohio Admin. Code 4729-5-18
  • 15. Ohio Admin. Code 4729-5-27
  • 16. Ohio Admin. Code 4729-5-29

 

Medical Records Collection, Retention, and Access in Ohio

Subtopic Statute/Regulation Description
Content of medical record Admission; transfer; discharge – ambulatory surgical facilities – Ohio Admin. Code 3701-83-17 Each ambulatory surgical facility must conduct a comprehensive medical history, physical exam and pre-procedure studies for each patient before an...
Central clinical record – Ohio Admin. Code 3701-19-23 Each hospice care program must establish and maintain a central clinical record for each patient receiving care and services from the program. All...
Confidentiality of patient records – Ohio Admin. Code 4729-5-29 Records relating to the practice of pharmacy, the administration of drugs, or any patient-specific drug transaction are not public records.  A...
Confidentiality – Ohio Rev. Code Ann. § 5123.31 The department of developmental disabilities will keep in its office, accessible only to its employees or by consent of the department or the order...
Licensure recordkeeping requirements – Ohio Admin. Code 3701-7-16 As a condition of licensure, maternity units and newborn care nurseries must maintain a medical record for each patient for five years that documents...
Medical record – Ohio Admin. Code 3701-83-49 As a condition of licensure, each freestanding radiation therapy center must document in the patient medical record the following information:...
Medical records requirement - Ohio Admin. Code 3701-83-54 As a condition of licensure, each freestanding or mobile diagnostic imaging center must record in the diagnostic imaging radiology report the...
Medical records – Ohio Admin. Code 3701-83-21 Each ambulatory surgical facility must maintain a record for each patient that contains the following information as applicable to the surgery to be...
Medical records – Ohio Admin. Code 3701-83-23.3 Each patient medical record maintained by a health care facility  (HCF) must include the following information: Patient information...
Medical records – Ohio Admin. Code 3701-83-23.3 Each patient medical record maintained by a health care facility (HCF) must include the following information: Patient information including...
Patient profiles – Ohio Admin. Code 4729-5-18 All pharmacies must maintain a patient profile system which will provide for immediate retrieval of information regarding those patients who have...
Physician, hospital and department abortion reports – Ohio Rev. Code Ann. § 3701.79 An attending physician must complete a confidential abortion report for each abortion he performs.  The report may not contain the woman’s...
Record keeping – Ohio Admin. Code 4729-5-27 “Record keeping”   All records relating to the practice of pharmacy, including prescription information entered into the record-...
Records and reports – Ohio Admin. Code 3701-17-19 Every nursing home must maintain an individual medical record for each resident, started immediately upon admission and containing the following...
Records and reports – Ohio Admin. Code 3701-17-67 Each residential care facility must maintain the following records:  An individual record for each resident, stored in a manner that...
Records – Ohio Rev. Code Ann. § 5119.06 The department of mental health must keep in its office, accessible only to its employees, a record with the following information for every patient...
Records – Ohio Rev. Code Ann. § 5120.21 “Records”   The department of rehabilitation and correction shall keep records showing the name, residence, sex, age, nativity,...
Resident assessments; tuberculosis testing – Ohio Admin. Code 3701-17-10 Each nursing home must require a written initial and periodic assessment of all residents.  Prior to admission of a resident, a nursing home...
Resident health assessments – Ohio Admin. Code 3701-17-58 Residential care facilities must conduct initial health assessments and annual reassessments (or sooner if medically indicated) of prospective and...
Right to access to medical records (Access by representative or other person authorized by the patient through informed consent; copying fees, or other requirements (e.g., requirement to give patient access in electronic format)) Cancer incidence surveillance system rules – Ohio Rev. Code Ann. § 3701.262 Each physician, dentist, hospital, or person providing diagnostic or treatment services to patients with cancer is responsible for reporting each...
Confidentiality – Ohio Rev. Code Ann. § 5123.89 All certificates, applications, records and reports that identify a resident or former resident of an institution for the mentally retarded or person...
Emergency medical or funeral service worker exposed to contagious or infectious disease may request notice of test results – Ohio Rev. Code Ann. § 3701.248 An emergency medical services worker or funeral services worker who believes that he has sustained significant exposure through his contact with a...
Fees for providing copies of medical records – Ohio Rev. Code Ann. § 3701.741 When a patient or a patient's personal representative requests a copy of the patient's medical record, the health care provider or medical records...
Managed health care programs: member rights – Ohio Admin. Code 5160-26-08.3 Managed health care program members have the following rights: To be ensured of confidential handling of information concerning their diagnoses,...
Patient care policies – Ohio Admin. Code 3701-83-07 Every healthcare facility must develop and follow comprehensive and effective patient care policies that include the following rights for each...
Patient care policies – Ohio Admin. Code 3701-84-07 The provider of a health care service  (HCS) must develop and follow comprehensive and effective patient care policies that include the...
Recordkeeping – Ohio Admin. Code 5122-33-15 Adult care facilities must maintain a record for each resident that contains the following: The resident’s name, previous address, date of...
Residents’ rights – Ohio Rev. Code Ann. § 3721.13 “Residents’ rights”   Each resident of a skilled nursing facility has the following rights: ·    ...
Review of plans of care and individual service plans – Ohio Rev. Code Ann. § 5166.05 The department of job and family services may review and approve, modify, or deny written plans of care and individual service plans created for...
Subject of report or representative has right to report and related records – Ohio Rev. Code Ann. § 5123.613 Upon the death of an individual with mental retardation or a developmental disability who was the subject of an abuse, neglect or unusual incident...
Written request for access to recorded personal information – Ohio Rev. Code Ann. § 3904.08 If any individual submits a written request to an insurance institution, agent, or insurance support organization for access to his recorded personal...
Destruction, storage and filing of medical records (Cross reference with Security of Health Information) Central clinical record – Ohio Admin. Code 3701-19-23 Each hospice care program must establish and maintain a central clinical record for each patient receiving care and services from the program. All...
Confidentiality – Ohio Rev. Code Ann. § 5123.89 All certificates, applications, records and reports that identify a resident or former resident of an institution for the mentally retarded or person...
Duties of state and local agencies maintaining personal information systems – Ohio Rev. Code Ann. § 1347.05 Every state or local agency that maintains a personal information system must take reasonable precautions to protect personal information in the...
General medical records requirements – Ohio Admin. Code 3701-83-11 Each health care facility (HCF) must maintain a medical record for each patient for six years from the date of discharge that documents the patient...
Recordkeeping – Ohio Admin. Code 5122-33-15 Adult care facilities must maintain a record for each resident that contains the following: The resident’s name, previous address, date of...
Records and reports – Ohio Admin. Code 3701-17-19 Every nursing home must maintain an individual medical record for each resident, started immediately upon admission and containing the following...
Review of plans of care and individual service plans – Ohio Rev. Code Ann. § 5166.05 The department of job and family services may review and approve, modify, or deny written plans of care and individual service plans created for...
Required maintenance of medical records Duty of covered entities – Ohio Rev. Code Ann. § 3798.03 This section applies to covered entities as they are defined in the HIPAA administrative regulation provisions (at 45 C.F.R. § 160.103)....
General medical records requirements – Ohio Admin. Code 3701-83-11 Each health care facility (HCF) must maintain a medical record for each patient for six years from the date of discharge that documents the patient...
General medical records requirements – Ohio Admin. Code 3701-84-11 The provider of a health care service (HCS) must maintain a medical record for each patient for five years from the date of discharge; such record...
General requirements for hospice care programs after licensure – Ohio Admin. Code 3701-19-07 As a condition of licensure, hospice programs are required to do the following: Establish an interdisciplinary plan of care for each hospice...
Licensure recordkeeping requirements – Ohio Admin. Code 3701-7-16 As a condition of licensure, maternity units and newborn care nurseries must maintain a medical record for each patient for five years that documents...
Provision of services – Ohio Rev. Code Ann. § 3712.06 Hospice programs must comply with the following requirements: Provide a planned and continuous hospice care program;  Establish an...
Public health laboratory responsibilities – Ohio Admin. Code 3701-55-03 The bureau of public health laboratories must provide screening for the presence of certain genetic, endocrine and metabolic disorders in newborn...
Records and reports – Ohio Admin. Code 3701-17-67 Each residential care facility must maintain the following records:  An individual record for each resident, stored in a manner that...
Registering and record keeping for nonprofit shelters and health care facilities – Ohio Rev. Code Ann. § 3701.071 Nonprofit shelters and nonprofit health care facilities must keep records of all patients who receive medical, dental, or other health-related...
Medical Records Collection, Retention, and Access Managed health care programs: program integrity – fraud and abuse, audits, reporting, and record retention – Ohio Admin. Code 5160-26-06 Managed health care programs (MCPs) must have administrative and managed arrangements or procedures, including a mandatory compliance plan, to guard...
Patient or patient’s representative to submit request to examine or obtain copy of medical record - Ohio Rev. Code § 3701.74 These requirements apply to hospitals, ambulatory care facilities, long-term care facilities, pharmacies, emergency facilities, and health care...