Comparing Medical Record Regulations for the State of Ohio, the Joint Commission and the

Centers for Medicare and Medicaid

Carla Pratt
University of Cincinnati Clermont

Comparing Medical Record Regulations for the State of Ohio, the Joint Commission and the
Centers for Medicare and Medicaid

The Health Insurance Portability and Accountability Act (HIPPA) requires covered
entities such as healthcare facilities and physicians to protect the privacy and security of
protected health information. These security measures can be implemented through
administrative, technical and physical safeguards. The Centers for Medicare and Medicaid
(CMS) and the Joint Commission both have recommendations for maintenance of medical
records; however, state rules and regulations regarding medical record processes should be
followed when specified.
According to the Ohio Department of Health (ODH), Ohio requires every patient medical
record maintained to be legible and easily accessible for medical staff. The medical record must
include the patients name, date of birth, gender, race or ethnicity. Like Ohio law, the Joint
Commission and Centers for Medicare and Medicaid require healthcare facilities to maintain
complete, legible records. The Centers for Medicare and Medicaid requires orders, reports and
notes to be dated, timed and authenticated in written or electronic form by the person responsible
for providing the service (CMS 2009).
In the state of Ohio, a patients history and physical should contain information about the
individuals allergies, current medications, pas adverse drug reactions and family medical
history. A specific timeframe is not noted for when the history and physical should be
documented in the patients record for Ohio. Medicare specifies a medical history and physical
should be completed and documented no more than 30 days before or 24 hours after admission

or registration (Farenholz & Russo). The Joint Commission also requires a patients history and
physical be charted or available electronically 24 hours after a patients admission to the hospital
however, Ohio makes no mention of a timeframe for the history and physical. Both CMS and the
Joint Commission require medical records to include physicians orders that contain the reason
for services. The Joint Commission also requires the orders be updated as the patients condition
progresses, CMS does not make this specification.
In Ohio healthcare providers are required to maintain medical records for six years from
the date of discharge as opposed to the 5 years required by Medicare conditions of participation.
Rules and regulations for the maintaining of psychiatric records are both lengthy for the state of
Ohio and the Centers for Medicare and Medicaid. Both require records to include but not limited
to patient demographic information, reason for admission and previous hospitalizations. CMS
and Ohio requires the legal status of the patient; in addition to this Ohio requires legal
documentation pertaining to civil commitment and guardianship.
Ohio providers are required to maintain adequate medical records and take the necessary
steps to prevent theft, loss, destruction and unauthorized use (ODH 2016). Providers are
prohibited from disclosing an individuals medical record unless authorized by the patient. CMS
also prohibits the release of protected health information to unauthorized individuals and to
provide security measures to prevent unauthorized individuals from accessing protected health
information.
The rules and regulations for maintaining medical records in Ohio mirror those of the
Centers for Medicare and Medicaid and the Joint Commission. While there are some differences

among the three, collectively they all come together in order to provide the outline for providers
to follow in order to maintain a complete, accurate and effective medical record.

References
Farenholz, C., Russo, R. (2013). Documentation for Health Records. Chicago, IL: AHIMA
Ohio Department of Health (2016). General Medical Records Requirements. Retrieved from
http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/rules/final/3701-80%20TO%2089/3701-84/3701-84-11.pdf
HCPro (2005). Know the JCAHOs Ongoing Records Review Requirements. Retrieved from
http://www.hcpro.com/HIM-53607-865/Know-the-JCAHOs-ongoing-records-reviewrequirements.html