What Patient Records Must a Hospital Maintain Under California Law? (22 CCR 72543)
The California Code of Regulations Title 22 section 71503 (22 CCR § 71503) requires that Medical Staff create rules that meet at least the minimum standards for patient record keeping.
California Code of Regulations Title 22 section 72543 details the minimum standards for Patients' Health Records.
Time to Maintain Records
Section 72543 states that “ All health records of discharged patients shall be completed and filed within 30 days after discharge date and such records shall be kept for a minimum of 7 years, except for minors whose records shall be kept at least until 1 year after the minor has reached the age of 18 years, but in no case less than 7 years”
Single, Organized Location
Modern electronic systems are essentially mandated. Section 72543 requires that “(g) All current clinical information pertaining to a patient's stay shall be centralized in the patient's health record.” Translated, this means that an established computer based system is required. This is emphasized in subsection (h) which reads “(h) Patient health records shall be filed in an accessible manner in the facility or in health record storage. Storage of records shall provide for prompt retrieval when needed for continuity of care.”
The real details of patient reporting are in Article 8 - Patient Data Reporting Requirements
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