Pennsylvania Code › Title 49 - PROFESSIONAL AND VOCATIONAL STANDARDS › Part I - DEPARTMENT OF STATE › Subpart A - PROFESSIONAL AND OCCUPATIONAL AFFAIRS › Chapter 16 - STATE BOARD OF MEDICINE-GENERAL PROVISIONS › Subchapter F - MINIMUM STANDARDS OF PRACTICE › Section 16.95 - Medical records

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A physician
					 shall maintain medical records for patients which accurately, legibly and
					 completely reflect the evaluation and treatment of the patient. The components
					 of the records are not required to be maintained at a single location. Entries
					 in the medical record shall be made in a timely manner.
(b) The medical record shall contain
					 information sufficient to clearly identify the patient, the person making the
					 entry if the person is not the physician-such as a physician assistant or a
					 certified registered nurse practitioner-the date of the medical record entry
					 and patient complaints and symptoms.
(c) Clinical information pertaining to the
					 patient which has been accumulated by the physician, either by himself or
					 through his agents, shall be incorporated in the patient's medical
					 record.
(d) The medical record
					 shall also include diagnoses, the findings and results of pathologic or
					 clinical laboratory examination, radiology examination, medical and surgical
					 treatment and other diagnostic, corrective or therapeutic procedures.
(e) A patient's medical record shall be
					 retained by a physician for at least 7 years from the date of the last medical
					 service for which a medical record entry is required. The medical record for a
					 minor patient shall be retained until 1 year after the minor patient reaches
					 majority, even if this means that the physician retains the record for a period
					 of more than 7 years.
(f) The
					 components of a patient's medical record, which are prepared by a physician or
					 his agent and which are retained by a health care facility regulated by the
					 Federal government, or by the Department of Health or the Department of Public
					 Welfare are considered to be a part of the patient's medical record which is
					 required to be maintained by a physician, but are otherwise exempt from the
					 requirements in subsections (a)-(e). These components of a patient's medical
					 record shall contain information required by applicable Federal regulations, or
					 by 28 Pa. Code (relating to health and safety) or 55 Pa. Code (relating to
					 public welfare)-see for example, Department of Health regulations at 28 Pa.
					 Code §§
											115.31-115.34 (relating to policies and
					 procedures for patient medical records)-and health care facility and medical
					 staff bylaws.
This section cited in 49 Pa. Code §
													18.15 (relating to practice
						  responsibilities of acupuncturist and practitioner of oriental medicine who is
						  not a medical doctor); 49 Pa. Code §
													18.158 (relating to prescribing
						  and dispensing drugs, pharmaceutical aids and devices); and 49 Pa. Code §
													18.159 (relating to medical
						  records).