---
kind: "section"
citation: "42 C.F.R. § 491.10"
title: "42"
number: "491.10"
heading: "Patient health records."
url: "https://uscodex.org/cfr/42/491.10"
---

# §491.10. Patient health records.

- (a) **Records system.**
  - (1) The clinic or center maintains a clinical record system in accordance with written policies and procedures.
  - (2) A designated member of the professional staff is responsible for maintaining the records and for insuring that they are completely and accurately documented, readily accessible, and systematically organized.
  - (3) For each patient receiving health care services, the clinic or center maintains a record that includes, as applicable:
    - (i) Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient;
    - (ii) Reports of physical examinations, diagnostic and laboratory test results, and consultative findings;
    - (iii) All physician's orders, reports of treatments and medications, and other pertinent information necessary to monitor the patient's progress;
    - (iv) **Signatures of the physician or other health care professional.**
- (b) **Protection of record information.**
  - (1) The clinic or center maintains the confidentiality of record information and provides safeguards against loss, destruction or unauthorized use.
  - (2) Written policies and procedures govern the use and removal of records from the clinic or center and the conditions for release of information.
  - (3) The patient's written consent is required for release of information not authorized to be released without such consent.
- (c) **Retention of records.** The records are retained for at least 6 years from date of last entry, and longer if required by State statute.

## Notes

### Amendments

[43 FR 30529, July 14, 1978. Redesignated at 50 FR 33034, Aug. 16, 1985, as amended at 57 FR 24984, June 12, 1992]

### Authority

Authority: 42 U.S.C. 263a and 1302.

### Amendments

[43 FR 30529, July 14, 1978. Redesignated at 50 FR 33034, Aug. 16, 1985, as amended at 57 FR 24984, June 12, 1992]