Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 130.000 - Hospital Licensure › Subpart C - SUPPLEMENTARY STANDARDS: IN GENERAL › Section 130.370 - Retention of Records

Current through Register 1525, July 5, 2024
(A) A hospital shall
				maintain records of the diagnosis and treatment of patients under its care for
				the retention period specified in M.G.L. c. 111, § 70 after the discharge
				or the final treatment of the patient to whom the record relates. Medical
				records may be handwritten, printed, typed or in electronic digital format, or
				converted to electronic digital format or an alternative archival method.
				Handwritten, printed or typed medical records that have been converted to
				electronic digital format or an alternative archival format may be destroyed
				before the expiration of the retention period specified in M.G.L. c. 111,
				§ 70. The manner of destruction must ensure the confidentiality of patient
				information. For purposes of 105 CMR 130.370, medical records in electronic
				digital format shall have the same force and effect as the original records
				from which they were made. A hospital shall include with the patient's medical
				record all trip records submitted by Emergency Medical Technicians on each
				ambulance run in accordance with
				105 CMR
				170.345(C). A hospital shall
				maintain the unprotected exposure forms in compliance with the requirements of
				105 CMR
				172.002(C).
(B) For the purpose of 105 CMR 130.370, a
				hospital shall not be required to consider the following as part of the medical
				record subject to the retention requirements in M.G.L. c. 111, § 70:
				radiological films, scans, other image records, raw psychological testing data,
				electronic fetal monitoring tracings, electroencephalograph,
				electrocardiography tracings and the like, provided that any signed narrative
				reports, interpretations or, sample tracings that are generated to report the
				results of such tests and procedures shall be maintained as part of the record.
				Such records as described in 105 CMR 130.370(B) shall be retained for a period
				of at least five years following the date of service.
(C) Medical records retained by the hospital
				in accordance with 105 CMR 130.370(A) or (B) shall be made available for
				inspection and copying upon written request of the patient or his or her
				authorized representative. The hospital may charge a reasonable fee for
				copying, not to exceed the rate of copying expenses as specified in M.G.L. c.
				111, § 70.
(D) A hospital
				shall maintain and use patient records in a manner that protects the
				confidentiality of the information contained therein. Printed copies of
				electronically stored records shall be destroyed in a manner that ensures the
				confidentiality of patient information.
(E) A hospital shall make all patient records
				available promptly to any agent of the Department.
(F) At the expiration of the retention period
				specified in M.G.L. c. 111, § 70, which begins after the discharge or the
				final treatment of the patient to whom a retained medical record relates, a
				hospital may destroy the medical record. The manner of destruction must ensure
				the confidentiality of patient information. At least 30 days prior to the
				proposed date of destruction of a medical record(s), a hospital shall provide
				written notification to the Department, generally indicating the type of
				records to be destroyed and the dates of service which exceed the applicable
				retention period, in a manner specified by the Department, of the hospital's
				intent to destroy medical record(s) that exceed the 20 year retention period. A
				hospital may, but is not required to, notify a patient before destroying the
				patient's medical record pursuant to 105 CMR 130.370.
(G) A hospital shall provide written notice
				to a patient of the patient's right to inspect and to receive a copy of the
				patient's medical records and the hospital's medical record retention policy,
				as specified in M.G.L. c. 111, § 70.
(H) The purpose of 105 CMR 130.370 is to
				establish a minimum retention period and does not preclude hospitals from
				maintaining records for a longer period of time.