Patient Case Records and Related Materials

providing summary and/or detailed information on patient:
RETENTION: Maintain as long as patient medical or other case record.
NOTES: Health agencies and facilities should consider permanent or long-term retention of the basic data elements of these systems for both administrative convenience and for potential research purposes. This data may provide for ease of access to other electronic and paper-based files and may create a record which replaces or supplements the master summary record (see item no. 738). Contact the State Archives for additional advice.

for individual patient, excluding those contained in medical case record:
RETENTION: 6 years

(in-patient and out-patient), excluding film, tracing, or other record of original entry when information contained is posted to or summarized in case record:
RETENTION: 7 years after death or discharge of patient, but not until 3 years after individual attains age 18
NOTES: Appraise these records for historical significance. These records may have continuing value for historical or other research, and the State Archives suggests hospitals consider permanent retention, or if not permanent, for at least 10 years after death or discharge of patient, based on American Medical Records Association guidelines. In addition, records of adoptive children may need to be retained longer for legal and medical reasons. Also, medical records of mothers may, in certain cases, need to be retained longer if needed relative to their children's health. The State Archives recommends that these factors be considered in disposing of medical case records, and that these records be evaluated for disposition on a case-by-case basis.

including but not limited to diagnostic or treatment center patient; child health, maternity, family planning, lead poisoning, medical rehabilitation, dental health, Indian reservation health, nutrition or tuberculosis clinic patient; health related social services and home health agency patient, but excluding early intervention program:
RETENTION: 7 years after discharge or last contact, but not until 3 years after youngest patient attains age 18

including X-ray, EKG tracing, EEG tracing, sonogram, echo cardiogram and holter monitor printout, when report of film or tracing is not incorporated into medical case record:
RETENTION: 6 years, or 3 years after minor patient reaches age 18, whichever is longer
NOTES: Holter monitor tapes need only be retained for one month after printouts ("disclosures") are produced from them.
Older X-rays on nitrate-base films, which 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.
Based on federal requirements (21 CFR Section 900.12 [c-4]), facilities conducting mammography activities (including operating mammography equipment or providing initial interpretation of the mammogram) must maintain mammograms and associated records of patients for 10 years, unless a subsequent mammogram was performed for that patient at the facility within that time, in which case the earlier mammogram can be destroyed after 6 years; or until the records are permanently transferred at patient request to another medical institution, physician or to the patient.

including those generated from patient data system (including documentation of macros, queries, and reports)

including emergency, voluntary, and involuntary admissions, that are not filed as part of a case file:
RETENTION: 10 years after discharge or last contact with patient, or 3 years after individual attains age 18, whichever is longer