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Pennsylvania Statutes Title 40 P.S. Insurance § 1303.511. Preservation and accuracy of medical records

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(a)?Timing.--Entries in patient charts concerning care rendered shall be made contemporaneously or as soon as practicable. ?Except as otherwise provided for in this section, it shall be considered unprofessional conduct and a violation of the applicable licensing statute to make alterations to a patient's chart.

(b)?Corrections and disposal of records.--It shall not be considered unprofessional conduct or a violation of the applicable licensing statute for a health care provider to:

(1)?Correct information on a patient's chart where information has been entered erroneously or where it is necessary to clarify entries made on the chart, provided that such corrections or additions shall be clearly identified as subsequent entries by a date and time.

(2)?Add information to a patient's chart where it was not available at the time the record was first created, provided that:

(i)?Such additions shall be clearly dated as subsequent entries.

(ii)?A health care provider may add supplemental information within a reasonable time.

(3)?Routinely dispose of medical records as permitted by law.

(c)?Alteration of records.--In any medical professional liability action in which the claimant proves by a preponderance of the evidence that there has been an intentional alteration or destruction of medical records, the court in its discretion may instruct the jury to consider whether such intentional alteration or destruction constitutes an adverse inference.

(d)?Licensure sanction.--Alteration or destruction of medical records for the purpose of eliminating information that would give rise to a medical professional liability action on the part of a health care provider shall constitute a ground for suspension. ?A health care provider who is aware of alteration or destruction in violation of this section shall report any party suspected of such conduct to the appropriate licensure board.

Cite this article: FindLaw.com - Pennsylvania Statutes Title 40 P.S. Insurance § 1303.511. Preservation and accuracy of medical records - last updated January 01, 2019 | https://codes.findlaw.com/pa/title-40-ps-insurance/pa-st-sect-40-1303-511/


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