10A NCAC 13D .2402       PRESERVATION OF MEDICAL RECORDS

(a)  The manager of medical records shall ensure that medical records, whether original, computer media or microfilm, be kept on file for a minimum of five years following the discharge of an adult patient.

(b)  The manager of medical records shall ensure that if the patient is a minor when discharged from the nursing facility, records shall be kept on file until his or her 19th birthday and, then, for five years.

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

(d)  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 take precautions to ensure the confidentiality and safekeeping of the records.  The original of the microfilmed medical records shall not be destroyed until the manager of medical records has had an opportunity to review the processed film for content.

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

(f)  All medical records are confidential.  Only authorized personnel shall have access to the records.  Signed authorization forms concerning approval or disapproval of release of medical information outside the facility shall be a part of each patient's medical record.  Representatives of the Department shall be notified at the time of inspection of the name and record number of any patient who has denied medical record access to the Department.

(g)  Medical records are the property of the facility, and they shall not be removed from the facility 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. 131E‑104;

Eff. January 1, 1996.