Public Health Regulations - Records Keeping


Public Health Regulations (Records Keeping), 1976-1 (5737)


Pursuant to my authority according to Section 33(I) of the Public Health Ordinance of 1940, I institute these regulations:

1.    Definitions (Amended, 5738)

In these regulations -

Record” – Everything which is written on paper or on a different material, every sketch, chart, drawing, mark, file, photocopy, photograph, film, recording and the like, which was produced following receipt of an individual to a hospital, in which he was treated from which he was released, including release following death, and other documents that were made in the hospital, or made in order to receive an individual to the hospital, as detailed in Column A of the addition;

            “ Hospital” – According to its definition in Section 24 of the ordinance;

            “ State Institution” – According to its definition in the Archives Law of 1955 (5715);

            “ Custodian” – A hospital manager or an individual who is authorized in writing for purposes of these regulations.

2.    Maintaining records (Amendment: 5757)

Every hospital will be responsible for maintaining records that were made in the hospital or that arrived to it, in a manner that will allow for locating them within a reasonable period of time.

3.    Removal of records from a hospital (Amendment: 5738)

(a) A record may not be removed from a hospital without written permission from the    custodian.

(b) In written permission for removal of a record, the custodian must indicate the reason for the removal and to whom it is being transferred.

(c) If an individual or his/her legal representative requests to transfer a record pertaining to him/her to another hospital, the custodian must order the transfer of the record according to the request of the individual or his/her legal representative.

(d) If a hospital closes or its records are canceled and there is not another hospital in its place, the hospital’s custodian must transfer the records that are in the hospital to a hospital which is a state institution, according to the manager’s instructions.

(e) If a record is removed from a hospital, unless as specified in Section (c), the custodian must keep a copy or photocopy in its place.

4.    Retention Period

(a) Subject to that stated in Regulation 3, a hospital must keep records that it is holding for the periods of time indicated in Column B of the addition.

(b) If a hospital photocopied a record on microfilm and if there is a photocopy on the same film of approval from the custodian that the photocopy is an exact copy of the original, it is not necessary to keep that record more than 30 days from the date of the photocopy.

(c) The hospital must keep the microfilm of every record that was photocopied as stated in Section (b) for the period of time determined in Column B of the addition regarding the original record.

(d) If a hospital doctor orders keeping a given record for a longer period of time than that indicated in Column B of the addition, the hospital must keep the record as ordered by the doctor.

(e) Regulations from Sections (a), (b) and (c) must not apply to hospitals that are state institutions or belonging to a local municipal authority.

5.    Validity

These regulations shall supplement all laws.

6.     Effective Date

These regulations shall become effective 30 days after their publication in the records.

7.    Transition Instructions

These regulations shall also be implemented on records in hospitals on their effective date.

Addition

(Regulation 1)


Column A

(1)  Medical records of a general hospital patient (not including an external clinic of the hospital), excluding an illness summary sheet.


(2)  Medical file of a patient in an external clinic of the hospital.



(3)  Illness summary sheet or summary letter to the treating doctor.

(4)  Patients receipt registry.

(5)  Registry of diagnoses and patients’ name index.

(6)  Emergency room documents.

(7)  Book of laboratory tests.

(8)  Book of surgeries.

(9)  Anesthesiologists’ book.

(10) Book of births.

(11) Copies of medical certificates removed according to the data in the medical file.

(12) X-ray registry.

(13) Photograph of x-ray, not including reports of findings according to the photograph.

(14) Institute or laboratory chart -
pathological finding.

(15) Institute or laboratory chart -
negative finding.

(16) E.K.G.




(17) Book of nurses’ reports, registry of doctors’ instructions.


(18) Book of nurses’ shift changes, treatment reports.

(19) Autopsy requirement form.

(20) Deceased registry.

(21) Protocol for opening a corpse.

(22) Microscopic histological finding report.

(23) Name index of histological-microscopic tests.

(24) Blood bank order.

(25) Blood bank transfusions card.

(26) Blood bank transfusions book.

(27) Blood bank blood type tests book.

(28) Blood bank blood preparation book.

(29) Blood donators’ book.

(30) Pregnancy termination approval.




(31) Book of deaths.

Column B

20 years after the hospitalization or the last treatment; and if there is no illness summary sheet – 25 years or 7 years after the patient’s death, the earlier of them.

7 years after the last treatment. If attached to the file in the hospital – according to the retention period of the medical file in the hospital.

100 years.


10 years after the last registry.

100 years after the last registry.


7 years.

10 years after the last registry.

10 years after the last registry.

10 years after the last registry.

100 years after the last registry.

7 years.



1 year after the last registry.

10 years after the last treatment in the x-ray photographs file or 7 years after the patient’s death, the earlier of them.

10 years.


2 years.


10 years. If the copy of the E.K.G. is retained in the medical file of the hospital – according to the retention period of the hospital.

7 years after the last registry, if the instructions were copied to the medical file – 30 days after the last copying.

7 year after the last registry.


10 years.

10 years.

25 years.

25 years.


25 years.


3 years.

7 years.

7 years after the last registry.

15 years after the last registry.

7 years after the last registry.

7 years after the last registry.

7 years after the last treatment; if attached to the medical file in the hospital – according to the retention period of the medical file in the hospital.

100 years after the last registry.

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1 Regulations 5737, 876, 468, 270; 5738, 732, 425; 5740, 1599; 5757, 415.

 

 

 

 

 

 

 

Translated by The Shira Pransky Project