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California Law (Last Updated: March 4, 2014) |
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Health and Safety Code - HSC |
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Division 106. PERSONAL HEALTH CARE (INCLUDING MATERNAL, CHILD, AND ADOLESCENT) |
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Part 1. GENERAL ADMINISTRATION |
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Chapter 1. Patient Access to Health Records |
Section 123130.
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(a) A health care provider may prepare a summary of the record, according to the requirements of this section, for inspection and copying by a patient. If the health care provider chooses to prepare a summary of the record rather than allowing access to the entire record, he or she shall make the summary of the record available to the patient within 10 working days from the date of the patient's request. However, if more time is needed because the record is of extraordinary length or because the patient was discharged from a licensed health facility within the last 10 days, the health care provider shall notify the patient of this fact and the date that the summary will be completed, but in no case shall more than 30 days elapse between the request by the patient and the delivery of the summary. In preparing the summary of the record the health care provider shall not be obligated to include information that is not contained in the original record.
(b) A health care provider may confer with the patient in an attempt to clarify the patient's purpose and goal in obtaining his or her record. If as a consequence the patient requests information about only certain injuries, illnesses, or episodes, this subdivision shall not require the provider to prepare the summary required by this subdivision for other than the injuries, illnesses, or episodes so requested by the patient. The summary shall contain for each injury, illness, or episode any information included in the record relative to the following:
(1) Chief complaint or complaints including pertinent history.
(2) Findings from consultations and referrals to other health care providers.
(3) Diagnosis, where determined.
(4) Treatment plan and regimen including medications prescribed.
(5) Progress of the treatment.
(6) Prognosis including significant continuing problems or conditions.
(7) Pertinent reports of diagnostic procedures and tests and all discharge summaries.
(8) Objective findings from the most recent physical examination, such as blood pressure, weight, and actual values from routine laboratory tests.
(c) This section shall not be construed to require any medical records to be written or maintained in any manner not otherwise required by law.
(d) The summary shall contain a list of all current medications prescribed, including dosage, and any sensitivities or allergies to medications recorded by the provider.
(e) Subdivision (c) of Section 123110 shall be applicable whether or not the health care provider elects to prepare a summary of the record.
(f) The health care provider may charge no more than a reasonable fee based on actual time and cost for the preparation of the summary. The cost shall be based on a computation of the actual time spent preparing the summary for availability to the patient or the patient's representative. It is the intent of the Legislature that summaries of the records be made available at the lowest possible cost to the patient.