26:8-5. Institutional records

The person in charge of a hospital, almshouse, lying-in, penal, or other institution, public or private, to which any person resorts for treatment of disease or for confinement, or is committed by process of law, shall make a record of all the personal and statistical particulars relative to each inmate in such institution, at the time of admission, and shall make a complete medical record covering the period of such person's confinement in such institution.

The medical records provided for herein or photographic reproductions thereof shall be retained by the custodian of records of such institution for a period of 10 years following the most recent discharge of the patient, or until the person confined therein reaches the age of 23 years, whichever is the longer period of time. In addition, a discharge summary sheet shall be retained by such custodian of records for a period of 20 years following the most recent discharge of the patient. The discharge summary sheet shall contain the patient's name, address, dates of admission and discharge and a summary of the treatment and medication rendered during the patient's stay. Any X-ray films related to such confinement, or any size reproductions thereof which maintain the clarity of the original shall be retained by such custodian of records for a period of 5 years.

In case of any person admitted or committed for treatment of disease, the physician in charge shall specify, for entry in the record, the nature of the disease and where, in his opinion, it was contracted.

The personal particulars and information required by this section shall be obtained from the individual himself if practicable; and when not, they shall be obtained in as complete a manner as possible from relatives, friends, or other persons acquainted with the facts.

Amended by L.1970, c. 288, s. 1, eff. Dec. 14, 1970; L.1975, c. 282, s. 1, eff. Jan. 12, 1976.