Medical Record Retention, Storage, Corrections, Electronic Health Records and Patient Access
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.
- Policy number
- CA-HSP-REC-02
- Version
- 1.0
- Main rule
- 22 CCR §74896
- Library
- California hospice · 60 policies
- Category
- Records
- Sections
- 24
In short
- 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.
What's inside
24 sections. The full text comes with the One-time Policy Pack.
- 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
An inspector may ask
- 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.
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