1, the state regulations in general medical records within 72 hours after the patient was discharged to the case room. In the medical institutions built outpatient medical records file, its outpatient medical records by the medical institutions are responsible for custody, not in the medical institutions to establish outpatient medical records file, its outpatient medical records by the patient is responsible for custody. Inpatient medical records are kept by the medical institution. In addition to medical personnel involved in the implementation of medical activities on the patient and medical service quality monitoring personnel, any other institutions and individuals shall not be unauthorized access to the patient's medical records. For scientific research, teaching the need to access the medical records, the relevant departments of the patient's medical institutions need to agree to access. It should be returned immediately after reading. The patient's privacy shall not be disclosed.
2, the legal basis: "Medical Records Management Regulations," Article 2
Medical records refers to the medical staff in the process of medical activities in the formation of text, symbols, charts, images, sections and other information, including outpatient (emergency) and hospitalization medical records.
Second, the medical record is kept for the longest period of time
According to the law, the medical record is divided into three kinds:
1, inpatient medical records, the hospital shall not be less than 30 years, lost or damaged are the responsibility of the hospital;
2, in the hospital to establish the file of outpatient records, the hospital storage time shall not be less than 15 years;
3, by the patient Preservation of outpatient medical records, including laboratory tests, checklists, registration ticket stubs, etc., these patients must be properly stored.