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The legal health record is the documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization.
Code § 16.95 - Medical records. (a) A physician shall maintain medical records for patients which accurately, legibly and completely reflect the evaluation and treatment of the patient. The components of the records are not required to be maintained at a single location.
(a) In General. Unless stipulated, to satisfy the requirement of authenticating or identifying an item of evidence, the proponent must produce evidence sufficient to support a finding that the item is what the proponent claims it is. (b) Examples.
Pa. R.E. 902(11) and (12) permit the authentication of domestic and foreign records of regularly conducted activity by verification or certification.
Rule 902(13) is solely limited to authentication, and any attempt to satisfy a hearsay exception must be made independently. A certification under this Rule can establish only that the proffered item has satisfied the admissibility requirements for authenticity.
In Pennsylvania, doctors must keep medical re- cords for seven years after the last treatment date. In the case of minor children, medical records must be kept for one year after the age of major- ity or for seven years, whichever is longer.
Under 42 Pa. C.S. §§ 6152, 6152.1 and 6155 (relating to subpoena ofrecords; limit on charges; and rights of patients), a health care provider or facility is allowed to charge a fee in response to a request for medical charts or records. The Secretary of Health (Secretary), under 42 Pa.
Rights of patients. (1) A patient or his designee, including his attorney, shall have the right of access to [all of] his medical charts and records and to [photocopy] obtain photocopies of the same, without the use of a subpoena duces tecum, for his own use.