Medical Records Collection, Retention, and Access |
Access - 6 Pa. Code § 11.197 |
Clients of older adult daily living centers will have access to their own records and the information contained therein, unless, in the opinion of... |
Clinical records - 28 Pa. Code § 211.5 |
Long term care facility’s clinical records must conform to the following requirements:
Information contained in the resident’s record... |
Clinical records - 28 Pa. Code § 601.36 |
Providers of home health care services must maintain a clinical record containing pertinent past and current findings for every patient receiving... |
Confidentiality - 28 Pa. Code § 5.53 |
Records and reports of examinations of specimens are confidential. 28 Pa Code Chapter 5, “Confidentiality” § 5.53
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Confidentiality - 40 Pa. Stat. Ann. § 991.2131 |
Managed care plans and utilization review entities must ensure that all identifiable information regarding enrollee health, diagnosis and treatment... |
Confidentiality of medical records - 28 Pa. Code § 115.27 |
Medical record confidentiality
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Confidentiality of medical records - 28 Pa. Code § 563.9 |
Records should be confidential
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Content of records - 6 Pa. Code § 11.193 |
Every older adult daily living center records must include the following information about the client:
Identifying information, including name,... |
Contents - 28 Pa. Code § 115.32 |
Medical record contents
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Contents of records - 28 Pa. Code § 5.52 |
The record must identify the person from whom the specimen was taken and include the result of the test. 28 Pa Code Chapter 5, “Contents of... |
Form and content of record - 28 Pa. Code § 563.12 |
Ambulatory surgical facilities must maintain a separate medical record for each patient that includes the following information:1
... |
Health record transfer, retention and confidentiality - 28 Pa. Code § 501.62 |
Birth centers must comply with the following requirements pertaining to patient medical records:
If a patient is transferred or referred to... |
Implementation - 28 Pa. Code § 103.22 |
All hospitals must establish a Patient’s Bill of Rights that contains the following provisions relating to patients:
The right, upon... |
Individual Record - 6 Pa. Code § 11.192 |
Each older adult daily living center must keep an individual record for each client.
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Medical records - 28 Pa. Code § 117.43 |
A medical record shall be kept for every patient receiving emergency service, including:
Patient identification data;
Time of arrival;
By... |
Medical records - 49 Pa. Code § 16.95 |
Physicians must maintain medical records for patients that accurately and completely reflect the evaluation and treatment of the patient and clearly... |
Medical records - 49 Pa. Code § 25.213 |
Every osteopathic physician must maintain a medical record for each patient that identifies the patient and provides pertinent clinical information,... |
Ongoing responsibilities of providers- 55 Pa. Code § 1101.51 |
Recipients of medical assistance may obtain services from any institution, agency, pharmacy, person or organization that is approved by the... |
Ownership - 28 Pa. Code § 115.28 |
Hospital medical records are the property of the hospital and may only be removed from the hospital premises for court purposes. Copies may be made... |
Ownership - 28 Pa. Code § 563.10 |
Ambulatory surgical facilities must maintain a separate medical record for each patient that includes the following information: 28 Pa. Code Chapter... |
Patient Access - 28 Pa. Code § 115.29 |
These requirements apply to hospitals.
A patient or his or her designee must be given access to or a copy of their medical records, or both, in... |
Patient medical records - 28 Pa. Code § 115.31 |
All hospitals must maintain patient records in accordance with the following provisions:
A medical... |
Patient medical records - 28 Pa. Code § 119.24 |
Outpatient services in hospitals must maintain an accurate medical record for every patient; outpatient service records must be made a part of the... |
Patient’s rights - 28 Pa. Code § 501.46 |
Birthing centers must have written policies and procedures that provide the following rights to patients:
Right to confidentiality, anonymity and... |
Preservation of medical records - 28 Pa. Code § 115.23 |
Preservation of medical records
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Professional records - 49 Pa. Code § 41.57 |
Psychologists must maintain a record for each client, which includes, at a minimum:
The name and address of the client/patient and, if the client... |
Record retention - 6 Pa. Code § 11.195 |
Older adult daily living centers’ client records must be kept for four years after a client’s departure, or until audits or litigation... |
Recordkeeping - 6 Pa. Code § 21.60 |
Each area agency on aging providing domiciliary care services must maintain a case record for each client receiving services; these records must... |
Records - 28 Pa. Code § 113.23 |
Hospital pharmacies must maintain the following:
A record of all drug transactions, correlated with... |
Records - 28 Pa. Code § 561.22 |
Ambulatory surgical facilities must provide pharmaceutical services; drug transactions of such services must be recorded, and those records must be... |
Report of findings - 28 Pa. Code § 5.47 |
A clinical laboratory may only report its findings to the person who submitted the specimen or requested the analysis, or to health officials as... |
Reportable diseases - 28 Pa. Code § 5.49 |
The director of the laboratory must report to the department of health all findings which indicate the presence of any reportable disease. 28 Pa.... |
Retention of reports - 28 Pa. Code § 5.51 |
Each laboratory must keep a record of test results for each specimen; if the laboratory is part of a hospital, the permanent laboratory record may be... |
Unprofessional and immoral conduct - 49 Pa. Code § 16.61 |
A Board-regulated practitioner who engages in unprofessional or immoral conduct is subject to disciplinary action. Unprofessional or immoral conduct... |