[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR491.10]



[Page 975]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 491_CERTIFICATION OF CERTAIN HEALTH FACILITIES--Table of Contents

 

Subpart A_Rural Health Clinics: Conditions for Certification; and FQHCs 

                         Conditions for Coverage

 

Sec.  491.10  Patient health records.



    (a) Records system. (1) The clinic or center maintains a clinical 

record system in accordance with written policies and procedures.

    (2) A designated member of the professional staff is responsible for 

maintaining the records and for insuring that they are completely and 

accurately documented, readily accessible, and systematically organized.

    (3) For each patient receiving health care services, the clinic or 

center maintains a record that includes, as applicable:

    (i) Identification and social data, evidence of consent forms, 

pertinent medical history, assessment of the health status and health 

care needs of the patient, and a brief summary of the episode, 

disposition, and instructions to the patient;

    (ii) Reports of physical examinations, diagnostic and laboratory 

test results, and consultative findings;

    (iii) All physician's orders, reports of treatments and medications, 

and other pertinent information necessary to monitor the patient's 

progress;

    (iv) Signatures of the physician or other health care professional.

    (b) Protection of record information. (1) The clinic or center 

maintains the confidentiality of record information and provides 

safeguards against loss, destruction or unauthorized use.

    (2) Written policies and procedures govern the use and removal of 

records from the clinic or center and the conditions for release of 

information.

    (3) The patient's written consent is required for release of 

information not authorized to be released without such consent.

    (c) Retention of records. The records are retained for at least 6 

years from date of last entry, and longer if required by State statute.



(Secs. 1102, 1833 and 1902(a)(13), Social Security Act; 49 Stat. 647, 91 

Stat. 1485 (42 U.S.C. 1302, 13951 and 1396a(a)(13)))



[43 FR 30529, July 14, 1978. Redesignated at 50 FR 33034, Aug. 16, 1985, 

as amended at 57 FR 24984, June 12, 1992]