As healthcare shifts to Electronic Health Records (EHRs), it is essential providers stay informed about the legal requirements for documenting, accessing, and retaining medical records. These records are vital for patient care and legal protection, and healthcare providers must ensure they comply with regulations outlined by the North Carolina Medical Board (NCMB).
Documentation Requirements
Healthcare providers are required to maintain accurate, up-to-date, and complete medical records. Entries must be made at the time of service, and patient confidentiality must always be upheld. These records protect both patient care and the provider in case of legal disputes.
There are requirements that all medical records should have such as: the purpose of each patient encounter, information of patient’s history, licensee’s clinical decision for care and treatment, notation of current medications or provided medications, and informed consent.
EHR Access and Security
With EHRs, safeguarding patient data is critical. Providers must implement strong security measures, including secure logins, encryption, and access controls to prevent unauthorized access. Only authorized personnel should access records, and patient consent may be needed to share information with third parties.
Retention of Medical Records
In North Carolina, medical records must be retained for at least 11 years after the last patient encounter. For minors, records must be kept until the patient turns 28. Healthcare providers must ensure their EHR systems comply with these retention rules.
Patients should be notified about how long the licensee will retain medical records. When destroying or retaining records, it should be done in a HIPAA compliant manner.
Legal Considerations
Failure to comply with medical recordkeeping laws can result in penalties, malpractice claims, or disciplinary actions. At Revolution Law Group, we offer expert legal guidance to help healthcare providers navigate these complex regulations and ensure compliance.
Revolution Law is ready to help you! For more information or assistance with your practice’s legal needs, contact us today.
Revolution Law Group is located in Greensboro, NC, and serves individuals and small businesses throughout the Triad and surrounding areas. To contact us please visit Revolution.law or call 336-333-7907.
The information included here is for informational purposes only, is not exhaustive of all considerations when creating documents, is not intended to be legal advice, and should not be relied upon for that purpose. We strongly recommend you consult with an attorney and do not attempt to create your own documents.