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California Health And Safety Code Section 123130

Legal Research Home > California Lawyer > Health and Safety Code > California Health And Safety Code Section 123130

(a) A health care provider may prepare a summary of the
record, according to the requirements of this section, for inspection
and copying by a patient.  If the health care provider chooses to
prepare a summary of the record rather than allowing access to the
entire record, he or she shall make the summary of the record
available to the patient within 10 working days from the date of the
patient's request.  However, if more time is needed because the
record is of extraordinary length or because the patient was
discharged from a licensed health facility within the last 10 days,
the health care provider shall notify the patient of this fact and
the date that the summary will be completed, but in no case shall
more than 30 days elapse between the request by the patient and the
delivery of the summary.  In preparing the summary of the record the
health care provider shall not be obligated to include information
that is not contained in the original record.
   (b) A health care provider may confer with the patient in an
attempt to clarify the patient's purpose and goal in obtaining his or
her record.  If as a consequence the patient requests information
about only certain injuries, illnesses, or episodes, this subdivision
shall not require the provider to prepare the summary required by
this subdivision for other than the injuries, illnesses, or episodes
so requested by the patient.  The summary shall contain for each
injury, illness, or episode any information included in the record
relative to the following:
   (1) Chief complaint or complaints including pertinent history.
   (2) Findings from consultations and referrals to other health care
providers.
   (3) Diagnosis, where determined.
   (4) Treatment plan and regimen including medications prescribed.
   (5) Progress of the treatment.
   (6) Prognosis including significant continuing problems or
conditions.
   (7) Pertinent reports of diagnostic procedures and tests and all
discharge summaries.
   (8) Objective findings from the most recent physical examination,
such as blood pressure, weight, and actual values from routine
laboratory tests.
   (c) This section shall not be construed to require any medical
records to be written or maintained in any manner not otherwise
required by law.
   (d) The summary shall contain a list of all current medications
prescribed, including dosage, and any sensitivities or allergies to
medications recorded by the provider.
   (e) Subdivision (c) of Section 123110 shall be applicable whether
or not the health care provider elects to prepare a summary of the
record.
   (f) The health care provider may charge no more than a reasonable
fee based on actual time and cost for the preparation of the summary.
  The cost shall be based on a computation of the actual time spent
preparing the summary for availability to the patient or the patient'
s representative.  It is the intent of the Legislature that summaries
of the records be made available at the lowest possible cost to the
patient.

Last modified: January 12, 2009