<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".04" citation="COMAR 10.01.16.04" title_num="10" subtitle_num="01" chapter_num="16" heading="Maintenance of Medical Records.">
  <paragraph num="A.">
    <text>A health care provider shall develop and maintain a records retention schedule compatible with the requirements of Regulations .04—.07 of this chapter.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Except as provided in Regulations .06 and .07 of this chapter, a health care provider shall maintain medical records for all patients in the health care provider's care for a minimum of 5 years after the medical record is made or until the patient is 21 years old, whichever is longer.</text>
  </paragraph>
  <paragraph num="C.">
    <text>Medical records are the personal property of the entity providing health care and are maintained for:</text>
    <paragraph num="(1)">
      <text>The patient;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The medical or treatment staff; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Other treatment, payment, and health care operations.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>A health care provider shall retain medical records in:</text>
    <paragraph num="(1)">
      <text>An office with access restricted to authorized staff;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>A computer or other device with appropriate security such as passwords or data encryption;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>A commercial records storage site with appropriate environmental and security controls; or</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Other storage options that ensure protection, security, and access control.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>Maintenance of medical records may be contracted to a records management service that agrees to comply with and be subject to this chapter.</text>
  </paragraph>
  <paragraph num="F.">
    <text>Medical records that have been placed in storage remain the responsibility of the health care provider, including:</text>
    <paragraph num="(1)">
      <text>Providing the patient or person in interest access to their medical records and authorized copies upon request in accordance with Health-General Article, §4-304, Annotated Code of Maryland, and 45 CFR §164.524, as amended;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Ensuring the confidentiality of the medical records;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Providing security and restricted access to the medical records; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Protecting the medical records from:</text>
      <paragraph num="(a)">
        <text>Damage;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Loss; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Deterioration.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>If a medical record is kept in electronic form, a health care provider shall:</text>
    <paragraph num="(1)">
      <text>Maintain or have access to compatible electronic hardware and software that will enable the health care provider to generate a legible copy of the record in order to comply with patient and governmental access needs; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Prepare and maintain a current back-up copy of electronic medical record files.</text>
    </paragraph>
  </paragraph>
</regulation>