Recordkeeping Requirements For Maryland Licensees
On a weekly basis, the Board answers many questions regarding recordkeeping retention, preparation, security and disposal. The following are collated from pertinent laws and regulations. You should refer to this information as needed.
Time Frame to Retain Adult Patient Records:
Maryland Health General Article, Section 4-301 et seq, and HIPAA regulations require that patient records be retained for six (6) years.
Time Frame to Retain Minor Patient Records:
Maryland Health General Article, Section 4-403(c) requires that minor patient records must be retained to the age of majority plus three (3) years or for five (5) years after the record is made, whichever is later.
Release of Records Upon Request by Patient:
COMAR 10.43.03.E requires that a licensee release a patient record upon written request by the patient or when compelled by law. Health General Article Section 4-304 requires that a licensee shall comply within a reasonable time for a patient request for a copy of records or to view the record. The Board interprets a reasonable time to be action within 24-48 business hours. The licensee should use a stock written request slip for the patient to sign.
Allowable Charges/Costs for Record Copying:
Health General Article, Section 4-307 allows licensees to charge copying costs for collation and copying of records and x-ray films. The licensee should notify the patient of these costs in advance. The best method is to have these pre-printed on the patient request form. The fees allowed are:
- Copy fee of .68 per page (actual costs may be charged for x-ray films)
- Preparation fee of not more than $20.52
- Actual cost of shipping and handling (e.g., if records must be retrieved from a remote storage site, the licensee may charge an hourly fee for collation and retrieval)
Non-Payment of Copy Fees:
Health General Article, Section 4-307(5)(d) allows the licensee to withhold copying of requested records until the fee is paid. However, the Board does not recommend this as it will prospectively generate patient ill will and could result in a formal complaint. A licensee may NOT refuse a request for a patient copy because of the failure of the patient to pay for health care rendered by the licensee.
Health General Article, Section 4-403(3) (e) requires that, upon the death or retirement of a licensee, the licensee or his/her estate in interest must publish a notice in a daily newspaper for 2 weeks stating that the records will be destroyed, transferred and where a patient may retrieve the patients before such destruction or transfer.
Destruction must not be done haphazardly. Records may not be dumped in a trash receptacle or left abandoned. Records should be shredded or incinerated. There are many companies that will professionally pick up and dispose of records and provide a verification receipt.
In addition to the Board charging the licensee for violations of laws and Regulations, pursuant to Health General Article, Section 4-403 (3) (g), a licensee can be administratively fined up to $10,000.00 for violating State record-keeping regulations.