General

1[356] Certification, licensing, and accreditation records covering review and approval by state or federal agency or professional review organization to operate facility or program, to conduct tests, or to perform specified work, including lists of permissible procedures or tests

RETENTION: 7 years after superseded, revoked, or no longer valid

2[357] Survey, evaluation, and inspection records covering review of facilities and programs by state or federal agency or professional review organization, including but not limited to medical care evaluation and similar studies

RETENTION: PERMANENT

3[359] Appointment records, including slips, return cards, sign-in sheets, and clinic schedules kept by facility or health services program

RETENTION: 0 after superseded or obsolete

4[360] Screening and assessment records and referrals for persons evaluated but not treated by facility or program

RETENTION: 3 years

5[754] Advice and referral records, covering medical, mental health, or other information provided to individuals in person or over the telephone, including but not limited to telephone logs and individual call records

a. When person involved is or becomes a patient

RETENTION: As long as patient case record is retained

b. When person involved is not or does not become a patient

RETENTION: 6 months

Fiscal

NOTE: Other fiscal records are covered in the Fiscal section in this Schedule.

6[361] Annual expenditure report or budget submitted to state or federal agency or professional review organization

RETENTION: PERMANENT

7[362] Patient’s individual financial case record and account

a. Individual case record, account card, or ledger card

RETENTION: 7 years after account closed, or 0 after 9 years, whichever is longer

b. Individual charge records, posted to case record or card

RETENTION: 7 years

8[363] Insurance carrier claim records, including but not limited to schedule of payments, copy of claim, listing of invalid or rejected claims, vendor payment list, list of claims submitted for payment, and list of checks received

RETENTION: 7 years

9[364] Insurance and reimbursement-related reports, including cost report, certified uniform financial or statistical report, and all necessary supporting documentation

RETENTION: 9 years

Facility and Patient Services

10[371] Census record of patients

RETENTION: 6 years

11[372] Nursing services report, including shift report

RETENTION: 1 year

12[755] Medical waste disposal records relating to generation, transportation, and disposal of regulated medical waste

a. Medical waste tracking records, including exception reports

RETENTION: 3 years after waste accepted for transport

b. Records created by generators who destroy regulated medical waste on site

RETENTION: 3 years after waste destroyed

c. Annual reports prepared by waste generator or transporter

RETENTION: 3 years

13[358] Master summary record, master index file, or principal register giving basic data on individual patients

RETENTION: PERMANENT

14[383] Film or tracing, including X-ray, EKG tracing, EEG tracing, sonogram, echo cardiogram and holter monitor printout, when report of film or tracing is retained as long as medical case record

RETENTION: 6 years

NOTE: Holter monitor tapes need only be retained for one month after printouts (“disclosures”) are produced from them.

NOTE: Older X-rays on nitrate-base films that have deteriorated to the point where they are no longer usable should not be retained. Retention of older nitrate-base X-rays may pose a serious fire hazard.

NOTE: Certain mammograms (covered by this item or by item no. 4 [360] in this section) must be retained for 10 years pursuant to requirements found in 21 CFR, Section 900.12 (c-4-i). Contact your Records Management Coordinator to determine what action is necessary to meet this requirement.

15[385] Communicable disease individual case records

a. Communicable disease case report or equivalent record, including copy of laboratory report

RETENTION: 6 years after discharge or last contact, or 0 after individual attains age 21, whichever is longer

b. Supplementary reports on communicable diseases

RETENTION: 2 years

c. Typhoid carrier records

RETENTION: 2 years after death or release of carrier

d. Syphilis treatment case record

RETENTION: 40 years

e. Sexually transmitted disease case record, except syphilis

RETENTION: 6 years, or 0 after individual attains age 21, whichever is longer

16[407] Individual immunization record, including authorization and/or parental consent

RETENTION: 6 years, or 0 after individual attains age 21, whichever is longer

17[408] Vaccine distribution and usage records

a. Official record of distribution and usage

RETENTION: 25 years

b. Statistical or similar record of vaccines administered

RETENTION: 5 years

18[98] Student health service case record

RETENTION: 6 years after last entry

Laboratory

19[388] Master summary record, including accession sheet or register

a. Register of laboratory tests performed

RETENTION: 7 years

NOTE: Appraise these records for archival value. These records may contain detailed information on the subject, nature, and results of laboratory tests and may have long-term or permanent scientific or historical research value. Contact your Records Management Coordinator for additional advice.

b. Record of collection of specimens

RETENTION: 7 years

20[759] Laboratory test data file, providing summary and/or detailed information on clinical laboratory tests performed and results

RETENTION: 7 years

NOTE: Data in these files may provide for ease of access to other electronic and paper-based files (such as accession records and laboratory test results) and may create a record that replaces or supplements the master summary record (see item no. 19 [388] in this section). Contact your Records Management Coordinator for additional advice.

21[391] Preventive maintenance, service, or repair record for laboratory equipment or instrument

RETENTION: As long as equipment or instrument remains in use and test results using equipment or instrument are retained

22[392] Quality control records covering laboratory equipment and procedures

RETENTION: As long as test results using equipment are retained, but not less than 2 years