10A NCAC 13B .3903      PRESERVATION OF MEDICAL RECORDS

(a)  The manager of medical records service shall maintain medical records, whether original, computer media, or microfilm, for a minimum of 11 years following the discharge of an adult patient.

(b)  The manager of medical records shall maintain medical records of a patient who is a minor until the patient's 30th birthday.

(c)  If a hospital discontinues operation, its management shall make known to the Division where its records are stored. Records shall be stored in a business offering retrieval services for at least 11 years after the closure date.

(d)  The hospital shall give public notice prior to destruction of its records, to permit former patients or representatives of former patients to claim the record of the former patient.  Public notice shall be in at least two forms: written notice to the former patient or their representative and display of an advertisement in a newspaper of general circulation in the area of the facility.

(e)  The manager of medical records may authorize the microfilming of medical records.  Microfilming may be done on or off the premises.  If done off the premises, the facility shall provide for the confidentiality and safekeeping of the records.  The original of microfilmed medical records shall not be destroyed until the medical records department has had an opportunity to review the processed film for content.

(f)  Nothing in this Section shall be construed to prohibit the use of automation in the medical records service, provided that all of the provisions in this Rule are met and the information is readily available for use in patient care.

(g)  Only personnel authorized by state laws and Health Insurance Portability and Accountability Act regulations shall have access to medical records.  Where the written authorization of a patient is required for the release or disclosure of health information, the written authorization of the patient or authorized representative shall be maintained in the original record as authority for the release or disclosure.

(h)  Medical records are the property of the hospital, and they shall not be removed from the facility jurisdiction except through a court order.  Copies shall be made available for authorized purposes such as insurance claims and physician review.

 

History Note:        Authority G.S. 90-21.20B; 131E-79; 131E-97;

Eff. January 1, 1996;

Amended Eff. July 1, 2009.