10A N.C. Admin. Code 13B.3903

Current through Register Vol. 39, No. 9, November 1, 2024

Section 13B .3903 - PRESERVATION OF MEDICAL RECORDS

(a) The manager of the medical records service shall maintain medical records that were created when the patient was an adult, whether original, computer media, or digital archived for 11 years following the discharge of an adult patient.

(b) The manager of medical records shall maintain medical records that were created when the patient was a minor, whether original, computer media, or digital archived, until the patient's 30th birthday. If a minor patient is readmitted as an adult, the manager of the medical records shall maintain medical records according to Paragraph (a) of this Rule.

(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 11 years after the closure date or according to Paragraph (b) of this Rule if the patient was a minor.

(d) The manager of medical records may authorize the digital archiving of medical records. Digital archiving 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 digital archived medical records shall not be destroyed until the medical records department has had an opportunity to review the digital record for content.

(e) 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.

(f) Only personnel authorized by State laws and the Health Insurance Portability and Accountability Act (HIPAA) found in 42 CFR 482, which is incorporated by reference including subsequent amendments and editions, shall have access to medical records. This regulation may be obtained free of charge at https://www.govinfo.gov/help/cfr. 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.

(g) Medical records are the property of the hospital, and shall remain the property of the hospital, except through a court order. Copies shall be made available for authorized purposes such as insurance claims and physician review.

10A N.C. Admin. Code 13B .3903

Authority G.S. 90-21.20B; 131E-79; 131E-97;
Eff. January 1, 1996;
Amended Eff. July 1, 2009.

Readopted by North Carolina Register Volume 38, Issue 05, September 1, 2023 effective 8/1/2023.