Medical Records Abstraction

(A) Qualifications and Training. Abstractors shall have the qualifications and training, as determined by the Commissioner, to accurately review and abstract records for the Congenital Anomalies Registry and shall maintain confidentiality at all times. Individuals selected as abstractors shall meet the minimum qualifications as defined by the Commissioner. (B) Purpose. When a physician or his or her agent has made a report to the Congenital Anomalies Registry but has not provided complete information that the commissioner requires for reporting, trained abstractors shall be given access to those parts of a medical record as are necessary to obtain information required to be reported and to verify the accuracy of reported information. (C) Access to Medical Records. (1) When a reported diagnosis occurs in Massachusetts in the office of a physician or in a licensed facility with a maternal-newborn service, neonatal intensive care unit, special care nursery service, continuing care nursery service, pediatric service, pediatric intensive care unit or with a medical specialty service as defined in 105 CMR 130.020 and when a physician or his or her agent has not provided complete information that the Commissioner requires for reporting, abstractors shall be given access to those parts of the medical record which are necessary to obtain information required to be reported and to verify the accuracy of reported information. Abstractors shall provide advance notice of an intention to inspect records. (2) Information from medical records of children and their parents relating to diagnostic information regarding congenital anomalies diagnosed prenatally, at delivery and three years of age or younger that is required to be reported to the Department is subject to abstraction without patient consent.