Patient Records

(A) Each clinic shall maintain centralized records documenting all the services rendered to clinic patients. Records shall contain sufficient information to justify the diagnosis(es) and treatment, and to document the results accurately. A mobile medical service or mental health outreach program shall maintain patient records as records of the clinic and not of the host locations or outreach location(s). (B) Each patient shall have a single integrated record, except mental health, dental, substance use disorder, and, upon approval of the Commissioner, other records, may be filed separately, provided there is an effective cross-referencing system. Each entry into each patient record shall be dated and authenticated by the staff member making the entry, including the staff’s name and title. Each page or each entry of each patient’s record shall have two unique forms of identification. The record with respect to each patient shall include the following: 140.302: continued (1) Patient’s name, date of birth, sex, home address and telephone number, and sponsor or responsible party if any. (2) Date of each patient visit with clinic staff at the clinic, satellite clinic or at mental health outreach sites. (3) Medical or dental history, as appropriate. (4) Diagnostic observations, evaluations, and therapeutic plans. (5) Orders for any medication, test, or treatment. (6) Records of any administration of medications, treatment, or therapy. (7) Laboratory, radiology, and other diagnostic reports. (8) Progress notes. (9) Reports of any consultations, special examinations, or procedures. (10) Operative and anesthesia records for surgical patients. (11) Social service reports. (12) Referrals to other agencies. (13) Documentation that informed consent has been obtained for surgical procedures and other treatment where required by law and in accordance with 105 CMR 140.301(B)(5)(e). (14) Discharge summary, when appropriate. (15) Documentation of patient consent to release information to the receiving provider prior to or upon patient transfer. (C) Retention of Medical Records. The purpose of 105 CMR 140.302(C) is to establish a minimum retention period and does not preclude clinics from maintaining records for a longer period of time. (1) In accordance with M.G.L. c. 111, § 70, each clinic shall maintain records of the diagnosis and treatment of patients under its care for a minimum of 20 years 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 converted to electronic digital format or an alternative archival format may be destroyed before the expiration of the 20-year retention period. The manner of destruction must ensure the confidentiality of patient information. For purposes of 105 CMR 140.302, medical records in electronic digital format shall have the same force and effect as the original records from which they were made. (2) For the purpose of 105 CMR 140.302, a clinic 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 reporting the results of such tests and procedures shall be maintained as part of the record. Such records as described in 105 CMR 140.302(C)(2) shall be retained for a period of at least five years following the date of service. (3) Medical records retained by the facility in accordance with 105 CMR 140.302(C) shall be made available, for inspection and copying, upon written request of the patient or his or her authorized representative. The clinic 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) Each clinic 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 disposed of in a manner that ensures the confidentiality of patient information. (E) Each clinic shall make all patient records available promptly to any agent of the Department. (F) At the expiration of 20 years after the discharge or the final treatment of the patient to whom a retained medical record relates, a clinic may destroy the medical record. The manner of destruction must ensure the confidentiality of patient information. At least 30 calendar days prior to the proposed date of destruction of a medical record(s), a clinic shall provide written notification to the Department generally indicating the type of records to be destroyed and the dates of service exceeding the applicable retention period, as specified in guidelines of the Department, of the clinic’s intent to destroy medical record(s) exceeding the 20-year retention period. A clinic may, but is not required to, notify a patient before destroying the patient’s medical record pursuant to 105 CMR 140.302. 140.302: continued (G) A clinic 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 clinic’s medical record retention policy, as specified in M.G.L., c. 111, § 70. (H) Each urgent care clinic shall provide a copy of the medical record of each visit to the patient at the end of the visit or as soon as available and, with the patient’s consent, provide a facsimile or electronically transmitted copy of the medical record of the visit to the patient’s primary care provider, if any. Such copies or transmission shall be provided at no charge to the patient.