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Patient Health Records














Student Health Services shall maintain a health record system from which information can be retrieved promptly, with appropriate safeguards of confidential patient information.  Health records shall be legible, documented accurately in a timely manner, and readily assessable to health care practitioners.








A.  A permanent health record including health history shall be established for all full-time, undergraduate and graduate students; and every student requesting care.  A log book is kept for staff/faculty visits.


B.      Health information gained must be kept confidential and used only in direct interest of the student.

1.       All records shall be kept in a secure place, with access limited to professional and necessary clerical staff of the health services.  All clerical staff are required to sign a confidentiality statement and follow Student Health Services’ Privacy Policy.

2.       All health records should be kept in locked, fireproof files when not in use or under the direct custody of health service personnel.

3.       Information from the health record shall be transmitted to third parties only after written authorization of the patient.  Exceptions are made following SHS Privacy Policy.

4.       Release of information contained in a minor’s health record will be in accordance with current Massachusetts State and/or Federal Law.

5.       Release of information related to HIV, AIDS or related illnesses will be in accordance with current Massachusetts State and/or Federal Law.

6.       All athletes evaluated in SHS, will sign an authorization for pertinent health information, which needs to be shared with the athletic trainer.  The authorization must be signed before participating in practice or competition.


C.        The health record should contain a continuous record of all visits or transactions

  within Health Services.  It should include:

1.       A pre-matriculation health history, physical examination within 15 months of matriculation, an immunization record and a tuberculosis screening questionnaire.

    1. All ambulatory visits to a nurse, nurse practitioner, physician or other health professional must be documented with a health record entry.  Each entry should contain the date, chief complaint, clinical findings, assessment of problem, diagnostic studies ordered, therapies or drugs administered, patient education and/or instruction provided, follow-up plan, referrals or consults, the provider’s signature and professional status.  All entries should be legible.
    2. Results of all laboratory or diagnostic tests.
    3. All medication allergies will be clearly documented on a red allergy sticker affixed to the upper right corner of the Health Examination Form.  Other allergies will be listed in the health history.
    4. Clinical summaries or other pertinent documents when the student has been treated elsewhere.
    5. A uniform format with sequential information.




D.      The clerical assistant of the Student Health Services shall be the custodian of the records and responsible for:

    1. The confidentiality, security and physical safety of the health records.  Records shall not be taken from Student Health Services for any reason, unless in the continuous, direct custody of the Health Services Director or the Medical Director.
    2. The timely retrieval of health records.
    3. The unique identification of each patient’s health record.
    4. The supervision of collection, processing, maintenance, storage, retrieval and distribution of health records.
    5. The maintenance of a predetermined, organized, health record format.


  1. The Student Health Services is responsible for retention of all health records.
    1. Student Health Records, with immunization information, will be retained for a period of 10 years following the end of the calendar year in which the documentation occurred.(National Childhood Vaccine Injury Act(NCVIA) of 1986,(Section 2125, of the Public Health Service Act).
    2. Student Health Records, with documentation of visits to SHS, will be retained for 30 years according to the Massachusetts Statewide Records Retention Guidelines.
    3. Inactive health records will be kept in fireproof, locked files as long as space allows.  If space becomes critical, files inactive for greater than five years will be scanned to an online database.  Original paperwork in the health record will then be shredded to protect client confidentiality.
    4. Records will be kept in accessible areas so that active records can be obtained immediately, and inactive records can be obtained within seven business days.
    5. Patient records retained by Student Health Services shall be made available to a patient following SHS privacy policy.
















Approved by Vice President/Date


 S. Brownlee

Approved by Cabinet/Date



Revised Date


Spring 2011





Last modified at 12/14/2011 12:39 PM  by Hoxha, Anisa