Md. Code Regs. 10.01.16.04 - Maintenance of Medical Records
A. A health care provider shall develop and
maintain a records retention schedule compatible with the requirements of
Regulations .04-.07 of this chapter.
B. Except as provided in Regulations .06 and
.07 of this chapter, a health care provider shall maintain medical records for
all patients in the health care provider 's care for a minimum of 5 years after
the medical record is made or until the patient is 21 years old, whichever is
longer.
C. Medical records are the
personal property of the entity providing health care and are maintained for:
(1) The patient ;
(2) The medical or treatment staff;
and
(3) Other treatment , payment,
and health care operations.
D. A health care provider shall retain
medical records in:
(1) An office with access
restricted to authorized staff;
(2)
A computer or other device with appropriate security such as passwords or data
encryption;
(3) A commercial
records storage site with appropriate environmental and security controls;
or
(4) Other storage options that
ensure protection, security, and access control.
E. Maintenance of medical records may be
contracted to a records management service that agrees to comply with and be
subject to this chapter.
F. Medical
records that have been placed in storage remain the responsibility of the
health care provider , including:
(1) Providing
the patient or person in interest access to their medical records and
authorized copies upon request in accordance with Health-General Article, §
4-304,
Annotated Code of Maryland, and 45 CFR § 164.524, as amended;
(2) Ensuring the confidentiality of the
medical records;
(3) Providing
security and restricted access to the medical records; and
(4) Protecting the medical records from:
(a) Damage;
(b) Loss; and
(c) Deterioration.
G. If a medical record is kept in
electronic form, a health care provider shall:
(1) Maintain or have access to compatible
electronic hardware and software that will enable the health care provider to
generate a legible copy of the record in order to comply with patient and
governmental access needs; and
(2)
Prepare and maintain a current back-up copy of electronic medical record
files.
Notes
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