§ 211.5. Medical records.
(b) Information contained in a residents record shall be privileged and confidential. Written consent of the resident or the resident representative is required for release of information, except as follows:
(1) Written consent is not necessary for authorized representatives of the Federal and State government during the conduct of their official duties.
(2) Written consent is not necessary for the release of medical records for treatment purposes in accordance with Federal and State law.
(d) Records of discharged residents shall be completed within 30 days of discharge. Medical information pertaining to a residents stay shall be centralized in the residents record.
(e) When a facility closes, resident medical records may be transferred with the resident if the resident is transferred to another health care facility. Otherwise, the owners of the facility shall make provisions for the safekeeping and confidentiality of resident medical records and shall provide to the Department, within 30 days of providing notice of closure under § 201.23 (relating to closure of facility), a plan for the storage and retrieval of medical records.
(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a residents medical record shall include at a minimum:
(i) Physicians orders.
(ii) Observation and progress notes.
(iii) Nurses notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(viii) Diagnostic and therapeutic orders.
(ix) Reports of treatments.
(x) Clinical findings.
(xi) Medication records.
(xii) Discharge summary, including final diagnosis and prognosis or cause of death.
(i) The facility shall assign overall supervisory responsibility for the medical record service to a medical records practitioner. Consultative services may be utilized; however, the facility shall employ sufficient personnel competent to carry out the functions of the medical record service.
The provisions of this § 211.5 amended under sections 102, 201(12), 601, 801.1 and 803 of the Health Care Facilities Act (35 P.S. § § 448.102, 448.201(12), 448.601, 448.801a and 448.803); and section 2102(a) and (g) of The Administrative Code of 1929 (71 P.S. § 532(a) and (g)).
The provisions of this § 211.5 adopted August 29, 1975, effective September 1, 1975, 5 Pa.B. 2233; amended January 31, 1987, effective July 1, 1987, 17 Pa.B. 514; amended July 23, 1999, effective July 24, 1999, 29 Pa.B. 3999; amended December 23, 2022, effective July 1, 2023, 52 Pa.B. 8098. Immediately preceding text appears at serial pages (329218) and (352793).
Notes of Decisions
Alteration of medical records during the course of a licensure survey in order to produce the appearance of compliance with regulations constitutes fraud and deceit justifying the Department of Health to refuse to renew a nursing home license. Colonial Gardens Nursing Home, Inc. v. Department of Health, 382 A.2d 1273 (Pa. Cmwlth. 1978).
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