As the role of Electronic Health Records (EHR) evolves, the impact on future medical record retention will also change. The medical record may be the property of the physician, but the information contained within it is the property of the patient. The suggested length of time the physician retains the record is variable. Medical Boards, society and association policies, as well as state and federal laws all influence the recommendations. Most state and federal laws apply to hospitals, not physician offices and Ohio does not have a general state law that medical records be kept for a minimum length of time. The following information will hopefully act as a guide to assist physicians in developing a medical records retention policy.
The medical record is the most important evidence in a medical malpractice case. If records are not available, it can be extremely difficult to defend a case. The main reasons for proper record retention:
- They provide medical information for optimal patient care
- They provide medical information to other healthcare providers
- They support the defense in a medical malpractice case
- They document the “standard of care” for insurance claims and future possible government requirements
- They fulfill the requirements of contracts (e.g., Medicare “conditions of participation” (COP)
As the legal environment in the United States grows in complexity, legal considerations will play an increased role in medical record retention decisions. Ohio law states that the action for a medical malpractice case must be brought within one year after cause of action “accrues”. The statute of limitations starts on the date the injury occurred or the date the patient should have “reasonably” discovered the injury. This statute can be extended as plaintiff may “discover” the casual relationship of the injury to care received beyond the one year limit. This means the record (theoretically) may need to be kept indefinitely.
As the interpretation of this statute is variable, hard and fast rules for medical record maintenance and retention are difficult to provide.
The following are reasonable suggestions:
- Retain records of a deceased adult for 10 yrs. after time of death
- For a minor, “statute of limitations” begins after their 18th The record would need to be retained for 10 yrs. beyond
- Immunization records should be retained permanently
- Medicare COP requires hospitals to retain records for 5 yrs
- Certain Medicare “Advantage” plans require hospitals to retain records for 10 yrs
- Ohio law recommends retention for 6 yrs. after last payment of services is received
- OSHA requests employers to retain records for 30 yrs. if employee was exposed to toxic substances or harmful agents
- HIPAA requires retention of the patient’s signed privacy policy for 6 yrs.
The following table is the recommendation of the American Health Information Management Association (AHIMA):
TABLE 1 – AHIMA’s Recommended Retention Standards
| Health Information | Recommended Retention Period |
| Diagnostic images (such as x-ray film) | 5 years |
| Disease index | 10 years |
| Fetal heart monitor records | 10 years after the infant reaches the age of majority |
| Master patient/person index | Permanently |
| Operative index | 10 years |
| Patient health/medical records (adults) | 10 years after most recent encounter |
| Patient health/medical records (minors) | Age of majority plus statute of limitations |
| Physician index | 10 years |
| Register of births | Permanently |
| Register of death | Permanently |
| Register of surgical procedures | Permanently |
Rules have not been initiated to date for EHR’s. It is recommended that hospital owned physician practices retain records according to their hospital policy.
PLPP suggests the following:
- Maintain records for a longer period than the statute of limitations (10 yrs. after the last visit for adults at a minimum)
- Maintain records of minors until 28 yrs. old (10 yrs. beyond their 18th birthday)
- Maintain billing documents for the same length of time as medical records
- Store records in a reputable document storage facility
- Destroy records by shredding or incineration
In conclusion, each provider should develop a policy and procedure for medical record retention. Legal council should be consulted for state compliance.
Disclaimer
The information and suggestions presented are to be viewed as aids to enhance patient care and safety. The intention is to be educational and is not a substitute for sound professional judgment, nor is it to be viewed as legal advice. Questions? Please contact PLPP.
plppoh.com 