(1) Records shall be kept on all patients admitted. All required patient health records, either as originals or accurate reproductions of the contents of such originals, shall be maintained in such form as to be legible and readily available upon the request of:
(A) The attending surgeon.
(B) Any authorized representative of the facility.
(C) Any authorized representative of the Office.
(D) Any other person authorized by law to make such a request.
(2) The medical record is the property of the facility and is maintained for the benefit of the patient, the medical staff and the facility. The facility shall safeguard the information in the record against loss, defacement, tampering or use by unauthorized persons.
(3) Patient records shall be preserved safely for a minimum of seven years following discharge of the patient, except that the records of unemancipated minors shall be kept at least one year after such minor has reached the age of 18 years and, in any case, not less than seven years.
(4) If a facility ceases operation, the Office shall be informed within 48 hours of the arrangements made for safe preservation of patient records as required.
(5) Medical records shall be filed in an easily accessible manner in the facility or in an approved medical record storage facility off the facility premises.
(6) Medical records shall be completed promptly and authenticated or signed by the attending surgeon within two weeks following the patient's discharge.
(7) Medical records shall be indexed according to patient's name, surgical procedure and attending surgeon.
Credits
Note: Authority cited: Section 1250.9, Health and Safety Code. Reference: Section 1250.9, Health and Safety Code.
1. New section filed 3-7-88 as an emergency; operative 3-7-88 (Register 88, No. 12). No Certificate of Compliance required pursuant to the provisions of Health and Safety Code section 1250.9(m).
2. Editorial correction of History No. 1 (Register 90, No. 21).
This database is current through 5/10/24 Register 2024, No. 19.
Cal. Admin. Code tit. 22, § 97530.9, 22 CA ADC § 97530.9
