12VAC5-410-1260: Medical records

A. An accurate and complete clinical record or chart shall be maintained on each patient. The record or chart shall contain sufficient information to satisfy the diagnosis or need for the medical or surgical service. It shall include, when applicable, the following:

1. Patient identification;

2. Admitting information, including patient history and physical examination;

3. Signed consent;

4. Confirmation of pregnancy;

5. Physician orders;

6. Laboratory tests, pathologist's report of tissue, and radiologist's report of x-rays;

7. Anesthesia record;

8. Operative record;

9. Surgical medication and medical treatments;

10. Recovery room notes;

11. Physician and nurse progress notes;

12. Condition at time of discharge;

13. Patient instructions, preoperative and postoperative; and

14. Names of referral physicians or agencies.

B. Provisions shall be made for the safe storage of medical records and the accurate and legible reproductions of medical records according to § 32.1-127.1:03 of the Code of Virginia and the Health Insurance Portability and Accountability Act ( (Pub. L. No. 104-191).

C. All medical records, either original or accurate reproductions, shall be preserved for a minimum of five years following discharge of the patient.

1. Records of minors shall be kept for at least five years after the minor has reached 18 years of age.

2. Birth and death information shall be retained for 10 years in accordance with § 32.1-274 of the Code of Virginia.

3. Record of abortions and proper information for the issuance of a fetal death certificate shall be furnished to the Office of Vital Records, Virginia Department of Health, as required by law.

D. An outpatient surgical hospital that makes health records, as defined in § 32.1-127.1:03 of the Code of Virginia, of patients who are minors available to patients through a secure website shall make the health records available to the patient's parent or guardian through the secure website, unless the hospital cannot make the health record available:

1. In a manner that prevents disclosure of information, the disclosure of which has been denied pursuant to § 32.1-127.1:03 F of the Code of Virginia; or

2. Because the consent required in accordance with § 54.1-2969 E of the Code of Virginia has not been provided.