{"ref":"CA-HSP-REC-02","title":"Medical Record Retention, Storage, Corrections, Electronic Health Records and Patient Access","category":"Records","summary":"Sets the rules for keeping and protecting medical records: 10-year retention (longer for minors); where hard copy records may be stored and when CDPH must approve off-site storage or an off-premises server; the electronic health record controls California requires, including backups at least every 24 hours and a downtime procedure; corrections within 48 hours and record completion within 30 days; patients' rights to inspect (within five working days), copy (within 15 days) and amend their records; and disposal, with notice to CDPH within 24 hours if records are destroyed early.","inShort":["Medical records are kept for at least 10 years after the patient's last service (longer for patients under 18).","To correct a mistake, draw one line through it or use the error stamp, write why, the date you found it and the date you fixed it, and sign. Fix errors within 48 hours.","If the electronic record is down, write on the paper downtime forms until it is back.","If a patient or family asks to see or copy a record, write the request down and give it to the records lead the same day. Copies must go out within 15 days.","Never take paper records home or leave them in a car, and never throw them in the trash."],"primaryCitation":"22 CCR §74896","citations":["22 CCR §74896","22 CCR §74900","22 CCR §74888(d)-(i)","22 CCR §74892(v)","22 CCR §74908(b)(7)","Cal. Health & Safety Code §123110","Cal. Health & Safety Code §123111","Cal. Health & Safety Code §123115","Cal. Civ. Code §56.101"],"federalCitations":["45 CFR §164.524","45 CFR §164.526","45 CFR §164.530(j)","42 CFR §418.104(d)-(e)"],"surveyorAsks":["How long do you keep medical records, and how do you work out the date for a minor?","Where are your hard copy records stored? If any are off-site, show me the CDPH approval."],"forms":[{"ref":"CA-HSP-REC-02-A","title":"Request to Inspect, Copy or Amend Medical Records"},{"ref":"CA-HSP-REC-02-B","title":"Off-Site Storage and Off-Premises Server Approval Checklist"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (22 CCR §74896)","5. Retention (22 CCR §74896(b))","6. Storage of Hard Copy Records (22 CCR §74896(c), (p)-(r))","7. Electronic Health Record Requirements (22 CCR §74900)","7.1 Sole authorship statement","8. When the EHR Is Down (22 CCR §74900(a)(5))","9. Corrections, Addenda and Mismatch Errors (22 CCR §74896(g)-(j))","10. Timeliness and Completion (22 CCR §74896(e)(2), (m))","11. Patient Access, Copies and Amendments (22 CCR §74888(e)-(f); Health & Safety Code §§123110, 123111)","11.1 Handling access requests","11.2 Deciding requests to amend (22 CCR §74888(f)(2))","12. Disposal and Destruction (22 CCR §74888(g)-(i))","13. Closure, Change of Ownership and Transfers","14. Responsibilities","15. Records and Compliance Monitoring","16. Staff Training","17. References","18. Related Policies and Forms","19. Approval","20. Revision History"],"version":"1.0","sample":false,"pack":"ca-hospice","state":"California","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}