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      Medical Record Retention

      Physicians have many responsibilities with respect to retaining medical records. A number of variables affect the length of time a physician should keep a medical record, such as state and federal laws, medical board and association policies, and the type of record (for example, an adult patient versus a pediatric patient record). The following information can guide physicians in developing their medical record retention policies.

      Basis for Keeping Medical Records
      The most important reason for keeping medical records is to provide information on a patient’s care to other health care professionals. Another major rationale is that a medical record that is well documented provides support for the physician’s defense in the event of a medical malpractice action. Without the medical record, the physician might not be able to show that the care he or she provided was appropriate and met the standard of care.

      State and Federal Laws
      For the most part, state and federal laws regarding mandatory record retention time frames apply to hospitals or similar facilities rather than to a physician’s clinic. The Medicare Conditions of Participation (COP) require hospitals to retain records for five years (six years for critical access hospitals),1 whereas OSHA requires an employer to retain medical records for 30 years for employees who have been exposed to toxic substances and harmful agents.2 HIPAA privacy regulations have a six-year retention requirement,3 which follows the federal statute for limitations for civil penalties.4

      Medical Board and Medical Association Policies and Recommendations
      When state or federal laws are silent on medical record retention, medical boards may have policies or recommendations on how long a physician should keep records. For example, the Colorado State Board of Medical Examiners Policy 40-07 recommends retaining medical records for a minimum of seven years after the last date of treatment for an adult and for seven years after a minor has reached the age of majority, or age 25.5 The California Medical Association has concluded that while a retention period of at least 10 years may be sufficient, it recommends that all medical records be retained indefinitely or, in the alternative, for 25 years.6

      Case Law
      A decision by the California Court of Appeals7 challenged the protection traditionally afforded to physicians by the statute of limitations. The court held that when an injury or abnormality did not manifest itself within the statute of limitation or if the patient could not have discovered the problem within the required time frame, the statute of limitations was suspended until the injury became apparent. As such, the time frame for the patient to bring a malpractice action was several years after the care was provided.

      Recommendations
      The Doctors Company recommends that physicians retain medical records for at least 10 years after the last visit for adult patients and up to age 28 for minors, or 10 years after the patient reaches majority. For California physicians, medical records should be retained for 25 years after the patient’s last visit. Some states allow records to be retained in an electronic format. For example, a paper record may be scanned to a computer or kept in another electronic format, such as microfilm. Paper records should be stored with a reputable document storage company.

      Such companies may offer alternative methods for document management, such as electronic scanning and storage, which physicians may want to consider. Storing closed or archived records at your residence puts you at risk of damage from fire or flood, loss due to theft, or other unauthorized access. You should also check state statutes and professional licensing agencies for state-specific requirements or recommendations.

      What Records Should You Retain?
      Retain all records that reflect the clinical care provided to a patient, including provider notes, nurses’ notes, diagnostic testing, and medication lists. Retain records obtained from another provider for the same length of time as those in your record. This is especially true if you have relied on any of the previous records or information when making current clinical decisions.

      As to billing records, physicians should review bills for any reference to care provided. For example, review the bill to determine if it shows a limited examination or an annual physical with diagnostic tests obtained or requested. If the billing document shows that care was provided, it may be in your best interest to keep the bill for as long as you retain the medical record. Otherwise, you need to retain it for the same length of time as other business records and in accordance with federal and state income tax requirements.

      The Doctors Company understands that there are financial implications behind these recommendations. However, given the importance of the medical record in defense of a malpractice action, it is vital for the physician to have the record available to defend proper care.

      J4280 9/08

       

      References:

      1. 42 CFR § 482.24(b)(1) and 42 CFR § 485.638(c).
      2 .29 CFR § 1910.1020(d)(1).
      3. 45 CFR § 164.530(j)(2).
      4. 42 CFR Part 1003.
      5. Colorado State Board of Medical Examiners Policy 40-07.
      6. Hanson CI, Meghrigian AG, Penney SL, Abrams GM. California Physician’s Legal Handbook. Vol. 4. San Francisco: California Medical Association; 2007:27:10.
      7. Brown v. Bleiberg, 32 Cal. 3rd 426, 186 Cal. Rptr. 228 (1982)

       

      About the Author

      This article was written by Laura A. Dixon, BS, JD, RN, CPHRM, Director, Department of Patient Safety, Western Region.


       

      The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.


      FIRST IN PATIENT SAFETY   |    www.thedoctors.com/patientsafety

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