CALIFORNIA - MEDICAL RECORDS

What is included in a patient’s medical records?

A patient's medical records include those documents related to the health history, diagnosis, or condition of a patient, or relating to treatment provided or proposed to be provided to the patient.

Who owns medical records?

Medical records are the property of the medical provider or facility that prepares them.

How long must a physician retain patient medical records?

California law does not specify how long a physician must generally retain patient medical records. However, there are several laws which require physicians to retain their records for a certain period of time. For example, there is a mandated 3-year retention period for all Medi-Cal patients, services reimbursed by Emergency Medical Services Fund, and when a physician prescribes controlled substances.

Cal Welf. & Inst. Code § 14124.1; Cal. Health & Safety Code §§ 1797.98(e), 11191

Further, the law requires HMO records to be maintained for a minimum of 2 years and Workers’ Compensation cases to be retained for 5 years. Licensed medical clinics should preserve their records for 7 years.

Cal. Health & Safety Code § 123145

Thus, while there is no precise rule regarding the retention of medical records, it is probably prudent to maintain patient records for at least 5 years, and 7 in the case of a licensed medical clinic.

What is a patient’s right to access medical records?

Under California law, a patient is entitled to inspect his or her medical records by issuing a written request to the physician and paying reasonable clerical costs to make the records available. Once the written request is received, the physician must allow the patient to view his medical records during business hours within 5 days from receiving the request. When viewing his records, the patient may be accompanied by someone else of his or her choosing.

Cal. Health & Safety Code §123110

Upon written request to the physician, a patient is also entitled to receive a copy of his medical records. The copies must be provided to the patient within 15 days of the receipt of the patient’s request.

Cal. Health & Safety Code §123110

California law also permits a physician to prepare a summary of the patient’s medical record rather than allowing the patient to access the entire record. The summary must be given to the patient within 10 working days of the patient’s request; however, a physician needing more time to produce the summary because of the extraordinary length of the medical record or because the patient was recently discharged, may notify the patient of the delay and provide a deadline for when the summary will be completed. In any case, the summary must be given to the patient no later than 30 days past the patient’s request.

When developing the summary, a physician may discuss the patient’s goals in obtaining his or her medical record. If the patient seeks only specific information (for example, regarding a specific illness), the provider summary need only included information relevant to the patient’s specific request. For each injury, illness, or episode of interest to the patient, the summary should include:

(1) Chief complaints including pertinent history;
(2) Findings from consultations and referrals;
(3) Diagnosis;
(4) Treatment plans and regimens;
(5) Progress of treatment;
(6) Prognosis;
(7) Reports of diagnostic procedures and tests;
(8) Objective findings from the most recent physical exam; and
(9) Medications prescribed and any known allergies.

Cal. Health & Safety Code §123130

May a physician charge a patient to access medical records?

A physician may charge patients reasonable clerical costs associated with producing the patient’s medical records. The fees can not exceed 25 cents per page or 50 per page for records copied from microfilm. When a patient requests copies of x-rays or tracings, they may be charged all reasonable costs, but this may not exceed the actual cost to the physician.

Cal. Health & Safety Code §123110

If a provider chooses to provide a summary rather than a patient record, the provider may charge the patient a reasonable fee based on the actual time and cost involved in preparing the summary. While there is no guidance regarding which exact amount may be charged, caution should be used when charging patients for summaries since the legislature has made it clear that all summaries of records should be available to patients at the lowest possible cost.

Cal. Health & Safety Code §123130

When may a physician refuse to provide a patient access to his or her medical records?

A physician may refuse to provide a minor’s records to the minor’s representative if the physician determines that access to the records will have a detrimental effect on the physician’s relationship with the minor or the minor’s physical safety or psychological well-being.

Cal. Health & Safety Code § 123115(a)

In addition, a physician may refuse a patient’s request to see or copy his or her own medical records if the physician determines there is a substantial risk of significant adverse or detrimental consequences to the patient is access were permitted.

When a physician refuses to provide the requested medical records, the physician must make a written note in the file of the patient’s request and the physician’s reason for refusal. The physician must then inform the patient of the refusal and that the patient has the right to have the documents reviewed by another health care professional.

Cal. Health & Safety Code § 123115(b)

May a patient amend his or her medical records?

A patient can not remove information in his or her medical record, but the patient can add an "Addendum" to be placed in the file. The addendum shall be limited to 250 words per alleged incomplete or incorrect item in the patient's record and shall clearly indicate the patient’s intent thatthe addendum be made part of his or her records.

Cal. Health & Safety Code § 123111

Copyright © Kern Augustine Conroy and Schoppmann, P.C. Used with permission.

Updated 2008