CONNECTICUT - MEDICAL RECORDS

I. CREATION, MAINTENANCE, AND PROVISION OF MEDICAL RECORDS

1. Must Physicians Create a Medical Record for Each patient?

Yes. The Connecticut Medical Examining Board (Board) requires that a medical record be created for each patient.

2. What Should the Medical Record Contain?

Physicians must prepare contemporaneous, permanent treatment records which reflect the actual treatment or services rendered.

Generally, the following should be contained within the treatment record:

A. Dates of all treatments;

B. Patient complaints;

C. Patient history;

D. Findings on appropriate examinations;

E. Progress notes;

F. Any orders for tests or consultations and the results thereof;G.Diagnosis or medical impression;

H. Treatment ordered, including specific dosages, quantities and strengths of medications, including refills, if prescribed, administered or dispensed, and recommended follow-up;

I. Physician's or provider's identity, if service is provided in multi-provider setting;

J. Any information regarding suggested actions to be taken that were nonetheless disregarded by the patient.

K. Information regarding any advance directive for healthcare for an adult or emancipated minor. Inquiry and documentation of this information must also be included on the routine intake history form for a new patient who is a competent adult or emancipated minor. In addition, the treating doctor must request and document this information when providing treatment for a significant illness, a life-threatening emergency, or where surgery is anticipated with use of general anesthesia;

L. Actions taken by non-licensed persons when ordered or authorized by the provider; and

M. Where applicable, birth certificate work-sheets.

C.G.S.A. § 20-14

3. Are There Requirements for Preparing and Maintaining Patient Records on a Computer?

While there are no specific provisions directly related to physicians, there is express authorization for health care institutions licensed by the Department of Public Health to create electronic medical records as long as the system is designed to "store medical records or patient health information in a medium that is reproducible and secure."

C.G.S.A. § 19a-25c

4. What are a Physician's Obligations to Provide Medical Records at the Request of the Patient?

Physicians must provide records to a patient or an authorized representative no later than 30 days from receipt of a request. The record must include all objective information such as test results and x-rays.

C.G.S.A. § 20-7c

5. May a Physician Withhold Medical Records Because the Patient Owes Money to the Physician for Services Rendered?

Not if the record is needed to render care. A physician must not refuse to provide a professional treatment record on the grounds that the patient owes an unpaid balance if the record is needed by another health care professional for the purpose of rendering care.

6.What are the Regulations Regarding a Company or an Organization's Medical Records of Employees?

A. Each employer must, within a reasonable time after receipt of a written request from an employee, permit the employee to inspect his or her medical record which is in the employer's possession. The employee may make such inspection only during regular business hours and at a location at or reasonably near the employee's place of employment. Each employer that has medical records pertaining to an employee must keep the record for at least three years following termination of employment. Medical records, if kept by an employer, must be kept separately and not as part of any personnel file.

C.G.S.A. § 31-128c

B. No individually identifiable information contained in the personnel file or medical records of any employee may be disclosed by an employer to any person or entity not employed by or affiliated with the employer without the written authorization of such employee except where the information is limited to the verification of dates of employment and the employee's title or position and wage or salary or where the disclosure is made:

(1) to a third party that maintains or prepares employment records or performs other employment-related services for the employer;

(2) pursuant to a lawfully issued administrative summons or judicial order, including a search warrant or subpoena, or in response to a government audit or the investigation or defense of personnel-related complaints against the employer;

(3) pursuant to a request by a law enforcement agency for an employee's home address and dates of his attendance at work;

(4) in response to an apparent medical emergency or to apprise the employee's physician of a medical condition of which the employee may not be aware;

(5) to comply with federal, state or local laws or regulations; or

(6) where the information is disseminated pursuant to the terms of a collective bargaining agreement.

C.G.S.A. §31-128f

7. What are the Regulations Regarding the Release of Medical Records Following a Workers' Compensation Examination?

The Board has provided that the Patient Records Rule applies to workers' compensation examinations and the patient is entitled to request and receive a copy of his or her patient records.

CT ADC § 19-13-D44

8. May a Physician Charge for Copying Costs of Medical Records?

Yes, a physician may charge no more than $.45 per page, including any research fees, handling fees or related costs, and the cost of first class postage, if applicable, for furnishing a health record pursuant, except that a physician may charge a patient the amount necessary to cover the cost of materials for furnishing a copy of an x-ray.

However, a physician may not charge for furnishing a health record or part thereof to a patient, a patient's attorney or authorized representative if the record or part thereof is necessary for the purpose of supporting a claim or appeal under any provision of the Social Security Act when the request is accompanied by documentation of the claim or appeal.

C.G.S.A. § 20-7c

9. How Long Must Physicians Retain Patient Medical Records?

Regulations require that treatment records be retained for:

A period of seven (7) years from the date of the most recent entry or upon the death of a patient, for three years.

Pathology Slides, EEG and ECG Tracings must each be kept for seven (7) years. If an ECG is taken and the results are unchanged from a previous ECG, then only the most recent results need be retained. Reports on each of these must be kept for the duration of the medical record.

Laboratory Reports and PKU Reports must be kept for at least five (5) years. Only positive (abnormal) laboratory results need be retained.

X-Ray Films must be kept for three (3) years.

CT ADC § 19a-14-42

II. CONFIDENTIALITY

1. What are the Exceptions to the General Rule that Physicians Must Maintain the Confidentiality of Medical Records?

A. A physician must release patient records as directed by subpoena, or other written demand under oath, when issued by the Connecticut Medical Examining Board or the Office of the Attorney General;

B. A physician must release records as required by law, such as the reporting of communicable diseases or gunshot wounds or suspected child abuse, etc., or when the patient's treatment is the subject of peer review;

C. If a physician reasonably determines that the information is detrimental to the physical or mental health of the patient, or is likely to cause the patient to harm himself or another, the physician may withhold the information from the patient. In such case, the information may be supplied to an appropriate third party or to another physician who may release the information to the patient. If disclosure of information is refused by a physician under this subsection, any person aggrieved thereby may, within thirty days of such refusal, petition the superior court for the judicial district in which such person resides for an order requiring the physician to disclose the information. The court, after hearing and an in camera review of the information in question, shall issue the order requested unless it determines that such disclosure would be detrimental to the physical or mental health of the person or is likely to cause the person to harm himself or another; and

D. A physician, in the exercise of professional judgment, who has a good faith belief that the patient, because of a mental or physical condition may pose an imminent danger to himself or to others, may release pertinent information to a law enforcement agency or other health care professional to minimize the threat of danger.

The above-listed exceptions do not apply to release of a record without patient consent that contains identifying information about a person who has AIDS or HIV infection. If a physician seeks to release information contained in an AIDS/HIV record to a law enforcement agency or health care professional to minimize the threat of danger to others, the physician must make an application to the court.

C.G.S.A. § 19a-25a; C.G.S.A. § 52-146o

2. Must Physicians also Assure the Confidentiality of a Patient's Record Where the Patient has Requested the Release of Records to a Specified Individual or Entity?

Yes. A physician must assure the confidentiality of medical records. To do so the physician should:

A. Secure and maintain a current HIPAA compliant written authorization signed by the patient or an authorized representative;

B. Assure that the scope of the release is consistent with the request; and

C. Forward the records to the attention of the specific individual identified and mark the material "Confidential."

45 CFR 164.512(b)(1); 45 CFR 164.528; 45 CFR 164.501

III. TERMINATION OF PRACTICE OR EMPLOYMENT

1. What Should be Done with Medical Records Upon a Physician's Death or Retirement?

Upon the death or retirement of a physician, the physician or the physician's surviving responsible relative or executor must provide notice to patients in a daily local newspaper published in the community which is the prime locus of the practice. This notice must be no less than two columns wide and no less than two inches in height. The notice must appear twice, seven days apart. In addition, an individual letter must be sent to each patient seen within the three years preceding the date of discontinuance of the practice. Medical records of all patients must be retained for at least sixty days following both the public and private notice to patients.

CT ADC § 19a-14-40

2. What Happens to Medical Records When a Physician is Terminated From a Group Practice?

While there is no State law or Board rule addressing this issue, the requirement to maintain a patient's medical record should be satisfied as long as a physician maintains possession and care of such record.

Any other allocation of the patient record as among remaining and departing physicians is generally a matter of private contractual agreement. Generally, any patient wishing to continue care with a departing physician is always free, under the rule for release of patient records, to request the custodian of the records to provide copies of the record to the patient directly or to transfer same to the departing physician at the new office location.

IV . DISPOSITION OF RECORDS

1. How Should Medical Records be Destroyed?

While there is no State law or Board rule addressing this issue, any method to be used for destroying medical records should generally protect confidential information and patient identity. Once notification requirements have been complied with, the physician should consider shredding or burning the documents rather than simply disposing of them in a garbage receptacle.

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