Board rule concerning medical records


540-X-9-.10 Joint Guidelines of the State Board of Medical Examiners and Medical Licensure Commission For Medical Records Management.

(1) Physicians should maintain legible well documented records reflecting the history, findings, diagnosis and course of treatment in the care of a patient. Medical records should be maintained by the treating physician for such period as may be necessary to treat the patient and for such additional time as may be required for medical-legal purposes.

(2) Access. On the request of a patient, and with the authorization of the patient, a physician should provide a copy or a summary of the medical record to the patient or to another physician, attorney or other person designated by the patient. By state law, a physician is allowed to condition the release of copies of medical records on the payment by the requesting party of the reasonable costs of reproducing the record. Reasonable cost as defined by law may not exceed one dollar ($1.00) per page for the first twenty-five (25) pages, fifty cents ($.50) per page for each page in excess of twenty-five (25) pages, a search fee of five dollars ($5.00) plus the actual cost of mailing the record. In addition, the actual cost of reproducing x-rays or other special records may be included. Records subpoenaed by the State Board of Medical Examiners are exempt from this law. Physicians charging for the cost of reproduction of medical records should give primary consideration to the ethical and professional duties owed to other physicians and to their patients, and waive copying charges when appropriate.

(3) Transfer or Disposal. When a physician retires, terminates employment or otherwise leaves a medical practice, he or she is responsible for ensuring that active patients receive reasonable notification and are given the opportunity to arrange for the transfer of their medical records. A physician or physician group should not withhold information from a departing physician which is necessary for notification of patients. A physician or the estate of a deceased physician transferring medical records in connection with the sale of a medical practice should notify the physician’s active patients that the records are being transferred and should provide the patient with information sufficient to secure the transfer of the medical record.

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