The psychiatrist conducting the independent medical review of an inpatient minor must keep a record of the proceeding. After considering all of the clinical information, the psychiatrist shall issue a binding decision whether to continue in-patient treatment.
Upon determination that a physician and surgeon has been rehabilitated and completed the diversion program, the program manager must destroy all of the physician and surgeon's treatment records. Other records may be retained as specified by regulations. All committee records and records of proceedings relating to a physician and surgeon's treatment in the diversion program are confidential and not subject to discovery or subpoena, except as authorized.
If the patient (or the patient's spouse or legal guardian) refuses to consent to the patient's transfer, the noncontracting hospital shall provide written notice indicating that the patient will be financially responsible for any further poststabilization care provided by the hospital. The hospital shall give one copy of the written notice to the patient (or the patient's spouse or legal guardian) for signature and may retain a copy in the patient's medical record.
If poststabilization care has been authorized by the health care service plan, the noncontracting hospital shall request the patient's medical record from the patient's health care service plan or its contracting medical provider. The health care service plan, or its contracting medical provider, shall transmit any appropriate portion of the patient's medical record via facsimile transmission or electronic mail, in a manner that complies with all legal requirements to protect the patient's privacy.
Every general acute care hospital and ambulatory surgery clinic shall file a data record with the Office of Statewide Health Planning & Development for each ambulatory surgery performed. This information is confidential and identifiable patient data shall be exempt from the Public Records Act.
When determining whether a provider has demonstrated that participants meet the medical necessity criteria, the Department of Health Services may enter an adult day health care center and review participants' medical records and observe participants receiving care identified in the individual plan of care, in addition to reviewing the information provided with the treatment authorization requests.
A minor may consent to the minor's medical care or dental care if the minor is 15 years of age or older, the minor is living separate and apart from the minor's parents, the minor is managing the minor's own financial affairs. A physician and surgeon or dentist may advise the minor's parent of the treatment given or needed if they have reason to know the whereabouts of the parent.
A hospital that transfers a patient for care and treatment to relieve/eliminate a psychiatric emergency medical condition shall (1) seek to obtain the name and contact information of the patient’s health care service plan and (2) notify the patient's health care service plan or the health plan's contracting medical provider of the transfer. The hospital shall document its attempt to ascertain this information in the patient's medical record.
A home dialysis agency shall maintain clinical records of all the patients, a medical history and physical provided by the patient's physician and surgeon. The physical shall be updated annually, and the annual update shall be maintained in the patient's medical files. the clinical records shall also include clinical progress notes written by the patient's physician and surgeon, a qualified registered nurse, a qualified social worker, and a dietician.