622-58 Retention of medical records. (a) Medical records may be computerized or minified by the use of microfilm or any other similar photographic process; provided that the method used creates an unalterable record. The health care provider shall retain medical records in the original or reproduced form for a minimum of seven years after the last data entry except in the case of minors whose records shall be retained during the period of minority plus seven years after the minor reaches the age of majority.

(b) Records exempt from the retention requirement are: public health mass screening records; pupils' health records and related school health room records; preschool screening program records; communicable disease reports; and mass testing epidemiological projects and studies records, including consents; topical fluoride application consents; psychological test booklets; laboratory copies of reports, pharmacy copies of prescriptions, patient medication profiles, hospital nutritionists' special diet orders, and similar records retained separately from the medical record but duplicated within it; public health nurses' case records that do not contain any physician's direct notations; social workers' case records; and diagnostic or evaluative studies for the department of education or other state agencies.

(c) X-ray films, electro-encephalogram tracings, and similar imaging records shall be retained for at least seven years, after which they may be presented to the patient or destroyed; provided that interpretations or separate reports of x-ray films, electro-encephalogram tracings, and similar imaging records shall be subject to subsection (e).

(d) Medical records may be destroyed after the seven-year retention period or after minification, in a manner that will preserve the confidentiality of the information in the record; provided that the health care provider retains basic information from each record destroyed. Basic information from the records of a physician or surgeon shall include the patient's name and birthdate, a list of dated diagnoses and intrusive treatments, and a record of all drugs prescribed or given. Basic information from the records of a health care facility, as defined in section 323D-2, shall include the patient's name and birthdate, dates of admission and discharge, names of attending physicians, final diagnosis, major procedures performed, operative reports, pathology reports, and discharge summaries.

(e) The health care provider, or the health care provider's successor, shall be liable for the preservation of basic information from the medical record for twenty-five years after the last entry, except in the case of minors, whose records shall be retained during the period of minority plus twenty-five years after the minor reaches the age of majority. If the health care provider is succeeded by another entity, the burden of compliance with this section shall rest with the successor. Before a provider ceases operations, the provider shall make immediate arrangements, subject to the approval of the department of health, for the retention and preservation of the medical records in keeping with the intent of this section.

(f) For the purposes of this section, the term "health care provider" means as defined in section 671-1. [L 1984, c 150, 2; am L 1986, c 176, 1; am L 1988, c 80, 1]

 

 

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