---
kind: "section"
citation: "42 C.F.R. § 494.170"
title: "42"
number: "494.170"
heading: "Condition: Medical records."
url: "https://uscodex.org/cfr/42/494.170"
---

# §494.170. Condition: Medical records.


The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of dialysis services and all other home dialysis patients whose care is under the supervision of the facility.

- (a) **Standard: Protection of the patient's record.** The dialysis facility must—
  - (1) Safeguard patient records against loss, destruction, or unauthorized use; and
  - (2) Keep confidential all information contained in the patient's record, except when release is authorized pursuant to one of the following:
    - (i) **The transfer of the patient to another facility.**
    - (ii) **Certain exceptions provided for in the law.**
    - (iii) **Provisions allowed under third party payment contracts.**
    - (iv) **Approval by the patient.**
    - (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program.
  - (3) Obtaining written authorization from the patient or legal representative before releasing information that is not authorized by law.
- (b) **Standard: Completion of patient records and centralization of clinical information.**
  - (1) Current medical records and those of discharged patients must be completed promptly.
  - (2) All clinical information pertaining to a patient must be centralized in the patient's record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient's condition and prescribed treatment.
  - (3) The dialysis facility must complete, maintain, and monitor home care patients' records, including the records of patients who receive supplies and equipment from a durable medical equipment supplier.
- (c) **Standard: Record retention and preservation.** In accordance with [45 CFR § 164.530(j)(2)](/cfr/45/164.530.md?p=j-2), all patient records must be retained for 6 years from the date of the patient's discharge, transfer, or death.
- (d) **Standard: Transfer of patient record information.** When a dialysis patient is transferred, the dialysis facility releasing the patient must send all requested medical record information to the receiving facility within 1 working day of the transfer.

## Notes

### Amendments

[73 FR 20475, Apr. 15, 2008, as amended at 89 FR 89213, Nov. 12, 2024]

### Authority

Authority: 42 U.S.C. l302 and l395hh.

### Source

Source: 73 FR 20475, Apr. 15, 2008, unless otherwise noted.

### Amendments

[73 FR 20475, Apr. 15, 2008, as amended at 89 FR 89213, Nov. 12, 2024]