Download - Allegheny County Medical Society

SPECIAL REPORT
Medical Records FAQs
Who owns patient medical records?
The Pennsylvania health facility
regulations specifically provide that
hospital medical records are owned
by the hospital. Although no Pennsylvania
statute, regulation or case
law directly addresses ownership of
physician office records, the general
consensus is that the physician office
records are owned by the physician,
not by the patient.
Physicians in Pennsylvania are
required by state regulation to retain
medical records for adult patients
for seven years from the last date of
service. Medical records for minor
Which financial and medical records
should I keep and for how long?
Document .............. How Long to Save
Accountant’s financials ........... permanently
Corporate tax returns .............. permanently
Insurance records and claims . permanently
Major legal correspondence .... permanently
Malpractice Insurance policies permanently
Medical correspondence ......... permanently
Patient claims .......................... permanently
X-rays ...................................... permanently
Cancelled checks ........................ 7 years
Charge slips and days sheets ..... 7 years
Expired contracts ......................... 7 years
Internal year-end financials ......... 7 years
Payroll records and tax returns ... 7 years
Purchase invoices ....................... 7 years
Third-party insurance claims ....... 7 years
Business correspondence ........... 3 years
Expired insurance policies .......... 3 years
Internal monthly summaries ........ 3 years
Personnel records ....................... 3 years
Bank statements and reconciliation1 year
Duplicate deposit slips ................. 1 year
Check with your accounting
and/or legal advisers with any
specific questions.
April 2012 : Bulletin
patients must be retained until he or
she turns 19 (MD) or 21 (DO), a
minimum of seven years. For more
information on state regulations,
visit www.pacode.com/secure/data/
049/chapter 16/s16.95.html.
In the case of a physician who is in
a group practice or employed by a
hospital or other facility, who owns
the medical records?
Physicians who are in a group
practice or employed by a hospital or
other facility should address ownership
of medical records in an applicable
partnership, employment, or
other legal agreement.
Are patients entitled to a copy of
their medical records?
Physicians are legally required under
state and federal law to provide
patients with access to their medical
records. Patients must be permitted
to review and obtain copies of their
medical records. Medical ethics also
require that patients be given access
to their medical records.
However, in certain situations, it
may be appropriate for a physician
to withhold information from a
patient to protect the patient or a
third party from harm. These
situations typically involve patients
who have received mental health
treatment.
Must a physician turn over the
original medical record to a patient?
As noted, office medical records
generally are considered to be the
property of the physician or group
practice. As a general rule, patients
(and their designees) are only entitled
to review their medical record
and obtain a copy. However, when
requested by patients (or their
representatives) mammography
facilities must provide original (not
copied) mammography films.
Is a subpoena required for patients
to obtain access to their medical
records?
No. However, patients need to sign
an authorization form and, if the
patient would like someone other
than himself or herself to receive a
copy of the medical record, it should
be noted on the authorization form.
When patients request a copy of
their medical records, must the
physician turn over records
forwarded by other providers?
The Pennsylvania laws and regulations
say: “Clinical information
pertaining to the patient which has
been accumulated by the physician,
either by himself or through his
agents, shall be incorporated in the
patient’s medical record.” That
includes medical records forwarded
by another office. Any information
in the medical record should be
copied and forwarded to the patient,
or the physician may face disciplinary
action, not only at the state level,
but the federal level under HIPAA.
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This infomation was gleaned from the
Pennsylvania Medical Society’s website
(www.pamedsoc.org). Our thanks to PAMED
for permission to use it in this Special Report.
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