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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:

7 years after superseded, revoked, or no longer valid
2.[357] Survey, evaluation, and inspection recordscovering 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:

PERMANENT

 

*3.[359]

Appointment records, including slips, return cards, sign-in sheets, and clinic schedules kept by facility or public health program:

NOTE: Appointment records for certain patients may have legal value to supplement patient medical records in documenting services provided to these patients.

0 after obsolete
4.[360] Screening and assessment records and referrals, for persons evaluated but not treated by facility or program: 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:

Retain as long as patient case record.
  b. When person involved is not or does not become a patient: 6 months
 

Fiscal

NOTE: Other fiscal records are covered by items on this Schedule found in the Fiscal section.

1.[361]

Annual expenditure report or budgetsubmitted to state or federal agency or professional review organization:

PERMANENT
2.[362] Patient's individual financial case record and account

 

 

  a. Individual case record, account card, or ledger card: 7 years after account closed, but not less than 9 years
  b. Individual charge records, posted to case record or card: 7 years
3.[363]

Medicare, Medicaid or 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:

7 years
4.[364] Insurance and reimbursement related reports, including Medicare/Medicaid cost report and certified uniform financial or statistical report, and all necessary supporting documentation: 9 years
*5.[365] Patient personal property records, including log or register of personal property of patients and receipts and related property records of original entry: 6 years after death or discharge of patient
 

Facility and Patient Services

1.[366]

Establishment, major alteration, or change of occupancy or use records

 
  a. Records of review and approval of plans, schedule of costs, feasibility studies, plans, specifications and drawings, final report, and significant correspondence:

PERMANENT

 

  b. Memoranda, routine correspondence, and supplemental fiscal documentation: 6 years after last entry
2.[367] Facility committee records  
  a. Minutes of medical staff committees, including but not limited to utilization review committee, joint conference committee or patient care conference: PERMANENT
  b. Records of medical staff committees,excluding minutes, including but not limited to agenda, worksheets and notes: 6 years
  c. Minutes and all other records of facility committee other than medical staff committees, such as dietary services committee or activities committee: 6 years
3.[368] Dietary services records  
  a. Food service records, including meal counts, roster of patients' diet orders, and dietary services studies: 3 years
  b. Menus: 1 year
4.[369] Patient activities records, including information on courses and activities offered to patients: 2 years
5.[370] Medical information index, including but not limited to physician's index, disease index and operative index: PERMANENT
*6.[371] Census record of patients: 6 years
7.[372] Nursing services report, including substation, shift and ward report: 1 year
8.[373] Hospital stay data collection recordscovering data collection and review by Statewide Planning and Research Cooperative System (S.P.A.R.C.S.) and Data Protection Review Board (D.P.R.B.)  
 

a. Request for data or review of data:

2 years
  b. Results of data processing: 0 after data verified
  c. Data received from S.P.A.R.C.S.: 0 after no longer needed for administrative purposes
*9.[374] Quality assurance records  
  a. Quality assurance plan, including staff privileges review procedures: PERMANENT
  b. Relating to quality of care provided by individual hospital staff members:

10 years after termination of employment

  c. Relating to quality of care provided individual patient, when not duplicated in medical case record: Retain as long as medical case record.
  d. Relating to more than one patient: Retain as long as all relevant medical case records are retained.
10.[375] Health facility infection control and monitoring records: 10 years
*11.[755] Medical waste disposal records, relating to generation, transportation and disposal of regulated medical waste  
  a. Medical waste tracking records, including exception reports: 3 years after waste accepted for transport
  b. Records created by generators who destroy regulated medical waste on site: 3 years after date waste destroyed
  c. Annual reports prepared by waste generator or transporter: 3 years
 

Patient Case Records and Related Materials

1.[358]

Master summary record, master index file, or principal register giving basic data on individual patients:

PERMANENT
*2.[756]

Patient data file, providing summary and/or detailed information on patient:

NOTE: Health agencies and facilities shouldconsider 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. 358, above). Contact the State Archives for additional advice.

Maintain as long as patient medical or other case record.

 

3.[376] Patient's leave records, including leave book or slip, patient's request, physician's consent and record of leave taken: 6 years
4.[377] Utilization review records for individual patient, excluding those contained in medical case record: 6 years
5.[378] Pre-admission screening records for long-term care health facility  
  a. When person is not admitted: 0 after obsolete
 

b. When person is admitted, and information is not duplicated in medical case record:

Retain as long as medical case record.
*6.[379]

Medical case record of hospital patient, (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:

NOTE: 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.

6 years after death or discharge of patient, but not until 3 years after individual attains age 18
7.[380] Medical case record of long-term care health facility patient: 6 years after death or discharge of patient, but not until 3 years after individual attains age 18
8.[381] Medical case record of out-patient, 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: 6 years after discharge or last contact, but not until 3 years after youngest patient attains age 18
*9.[382] Original entry patient care records which exist separately from case record, including nurses' notes, operating room record, therapy record, nursery and obstetrics record, emergency room treatment record, triage records, and temperature charts  
  a. When significant information is posted to medical case record: 6 years
 

b. When significant information is not posted to medical case record: 

Retain as long as medical case record.
*10.[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:

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, 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.

NOTE: Certain mammograms (covered by this item or by item no. 360, above) must be retained for 10 years pursuant to requirements found in 21 CFR, Section 900.12 (c-4-i). Consult your attorney or counsel to determine what action is necessary to meet this requirement.

6 years
11.[384] Patient care conference records, including worksheets and evaluations, but excluding minutes  
  a. When significant information is posted to medical case record: 0 after posting
 

b. When significant information is not posted to medical case record:

Retain as long as medical case record.
*12.[385] Communicable disease individual case records  
 

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

6 years after discharge or last contact, or 3 years after individual attains age 18, whichever is longer
  b. Supplementary reports on communicable diseases: 2 years
 

c. Typhoid carrier records:

2 years after death or release of carrier
  d. Syphilis treatment case record: 40 years
  e. Sexually transmitted disease case record,except syphilis: 6 years, or 3 years after individual attains age 18, whichever is longer
*13.[757]

Mental health incident report:

20 years
*14.[386] Mental health individual case record  
  a. Clinical discharge summary: 25 years
  b. Psychiatric test answer sheets: 6 years
 

c. Case record materials, except clinical discharge summary and psychiatric test answer sheets:

NOTE: Appraise these records for historical significance. Records covered by item nos. 386 and 387 may have continuing value for historical or other research. Contact the State Archives for additional advice in this area.

10 years after discharge or last contact with patient, or 3 years after individual attains age 18, whichever is longer
*15.[387] Alcohol or substance abuse individual case record including clinical discharge summary: 6 years after date of discharge or last contact, or3 years after individual attains age 18,or for the period required by contractual arrangements, whichever is longest
*16.[758] Reports, studies or data queries, including those generated from patient data system (including documentation of macros, queries, and reports)  
 

a. Reports, studies or queries relating to individual patient:

Retain as long as or as part of medical or other patient case record.
 

b. Reports, studies or queries not relating to individual patient:

NOTE: Appraise records covered by part "b" for archival value. Reports and studies analyzing specific medical conditions and their treatments may be valuable for long-term planning and for medical, historical and other research. Contact the State Archives for additional advice.

0 after no longer needed
 

Laboratory

*1.[388]

Master summary record, including accession sheet or register

 
 

a. Register of laboratory tests performed:

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 the State Archives for additional advice.

7 years
  b. Record of collection of specimens: 7 years
*2.[759] Laboratory test data file, providing summary and/or detailed information on laboratory tests performed  
 

a. For clinical laboratory tests:

Maintain as long as related laboratory tests results.
  b. For forensic or toxicology tests: 6 years
 

c. For environmental health tests:

NOTE: Laboratories 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 (such as accession records and laboratory test results) and may create a record which replaces or supplements the master summary record (see item no. 388, above). Contact the State Archives for additional advice.

Maintain as long as related laboratory tests results.
*3.[389] Request for laboratory test: Retain as long as the related test results or 7 years, whichever is shorter.
*4.[760] Referral information for cytogenetic cases: 6 years
*5.[390] Laboratory worksheet, workslip, history slip, or similar record  
 

a. For environmental health, or toxicology or forensic test:

Retain as long as related test results.
  b. For clinical laboratory tests: 1 year
*6.[391]

Preventive maintenance, service, or repair record for laboratory equipment or instrument:

NOTE: If equipment is used to produce laboratory tests which have differing minimum legal retention periods, then these preventive maintenance records must be retained as long as the longest period of time these laboratory test results need to be retained.

Retain as long as the equipment or instrument remains in use, and also as long as test results using this equipment are retained.
*7.[392]

Quality control records covering laboratory equipment and procedures:

NOTE: If equipment is used to produce laboratory tests which have differing minimum legal retention periods, then these quality control records must be retained as long as the longest period of time these laboratory test results need to be retained.

Retain as long as test results using this equipment are retained, but not less than 2 years.
8.[393] Laboratory protocol detailing procedures for conducting tests, disposing of specimens, samples and supplies, or other activity, including superseded or obsolete procedures: PERMANENT
*9.[394] Laboratory reports, studies or data queries, including those generated from automated data system  
  a. Forensic and other related investigation reports: 6 years
 

b. All other reports, studies or queries:

NOTE: Appraise these records for archival value. Reports and studies analyzing specific types of tests, test results and the population being tested may be valuable for long-term planning and for medical, historical and other research. Because these records will vary greatly as to content, subject and detail, they should be appraised for archival value. Contact the State Archives for additional advice.

0 after no longer needed
*10.[395] Laboratory specimens and slides  
  a. Blood film, routine: 6 months
  b. Blood film, other than routine: 1 year
  c. Cytology slide, showing abnormality: 7 years
  d. Cytology slide, showing no abnormality: 3 years
  e. Bone marrow biopsy, tissue block, and histopathology slide: 20 years
  f. Bacteriology slide, on which no diagnosis depends: 0
  g. Bacteriology slide, on which a diagnosis depends: 1 year
  h. Cytogenetic slide: 6 years
  i. Photographic record of cytogenetic karyotype: 25 years
  j. Recipient blood specimens: 1 week
*11.[396] Blood collection, release, transfusion and related records  
  a. When plasmapheresis, cytapheresis, intraoperative and postoperative blood recovery, isovolemic hemodilution or reinfusion is involved: 7 years after procedure involved
 

b. Other blood related records, including autogenic or allogenic transfusions:

7 years, or 6 months after the expiration date of the individual product, whichever is later
12.[397] Biologics receipt and distribution record  
  a. Detailed delivery record: 2 years
  b. Summary record of receipt and distribution: 5 years
13.[398] District laboratory supply station records  
  a. Notification of establishment or discontinuance of station or of appointment or termination of its caretaker: PERMANENT
  b. Certificate of approval of station maintenance: 2 years
  c. Periodic inventory of station supplies: 6 years
*14.[399] Laboratory examination test results (clinical)  
  a. Positive report of syphilis serology: 7 years
  b. Negative report of syphilis serology: 2 years
  c. Tissue pathology (including exfoliate cytology) report: 20 years
  d. Cytogenetics report: 25 years
  e. Clinical, except those listed above: 7 years
*15.[761]

Forensic and toxicology test results:

NOTE: These records may need to be retained as long as related case investigation records. Consult the appropriate law enforcement or investigative agency to determine if these records may be needed longer for legal purposes.

6 years
*16.[400] Laboratory examination test results (environmental health)  
  a. Chemical analysis of potable water supply: 10 years
 

b. Routine analysis of water at pool or beach:

0 after posted to summary record, or 3 years if not posted
  c. All other environmental health test results: 3 years
  d. Sampling data and other test results maintained by laboratory of public water supply facility, created pursuant to Section 5-1.49, 10 NYCRR: 12 years
  e. Local health agency copy of any environmental analysis received from laboratory: 1 year
 

Radiological Health

*1.[177]

Approvals and registrations relating to radiological equipment and materials

 
 

a. Approval to possess or use radioactive materials, received from New York State Department of Health, and related records:

3 years after local government, facility or program no longer possesses or uses radiological materials
 

b. Registration of radiation-producing equipment with New York State Department of Health, and related records:

2 years after expiration or renewal
*2.[178] Radiation-exposure records for an individual  
  a. Records of diagnostic misadministrations: 3 years
  b. Records of therapeutic misadministrations: 6 years
 

c. Radiation-exposure data for an individual, including records of radioactive material deposited or retained in body:

0 after individual attains age 90
*3.[762] Records of occupational doses for an individual using radiation-producing equipment or radiological materials  
  a. Annual or other summary occupational dose records: 0 after individual attains age 90
  b. Detailed occupational dose records: 0 after annual or other summary record containing this information is produced
 

c. Records of prior occupational dose:

0 after individual attains age 90
 

d. Records of planned special exposures:

0 after individual attains age 90
*4.[179] Radiation equipment testing and inspection records  
  a. Regulatory inspection and audit records, including master summary record and "index card": 6 years after equipment no longer in use
  b. Equipment accuracy testing records, including surveys, calibrations, measurements, and quality control tests: 3 years
*5.[180] Records of disposal, theft, loss, or excessive release of radiation  
  a. Records concerning theft or loss of radiation source, excessive release of radiation, or excessive exposure of individual to radiation, including documentation of notification: PERMANENT
  b. Record of disposal by burial in soil: PERMANENT
  c. Records of authorized transfer or receipt, or issue and return of radiation source or radioactive materials, or disposition by incineration or release into sanitary sewer system: 6 years
*6.[763] Radiation program safety records  
 

a. Records documenting provisions of program:

3 years after program ceases to exist
  b. Audits and other reviews of program content and implementation: 3 years
 

c. Records documenting specific instructions given to workers:

3 years
 

Miscellaneous

*1.[401]

Birth and death records held by health agency or facility, including copies of birth and death certificates, and related electronic records:

NOTE: The New York State Department of Health requires these records be destroyed as soon as no longer needed. Paper copies of birth and death certificates shall be destroyed within one year of the date of their receipt. Copies of fetal death certificates must be destroyed by the end of each month, pursuant to Section 4160, Public Health Law.

0 after no longer needed
2.[402] Medical rehabilitation service card: 6 months after completion of annual report
*3.[764] Dental clinic records  
 

a. Dental hygienist's clinic record:

0 after youngest person on record attains age 21
  b. Dental referral card, notifying clinic of work done by private dentist: 2 years
 

c. Individual dental treatment summary record:

6 years after dental work completed, or 3 years after individual attains age 18, whichever is longer
4.[403] Maternal and child health reports  
  a. Clinic service report, including but not limited to school health service report, and report of poisoning case, except lead poisoning: 1 year
  b. Individual newborn infant metabolic defects screening report: 0 after individual attains age 21
5.[406] Lead poisoning reports and screening results  
 

a. Positive results of screening, when notduplicated in case record:

Retain as long as case record.
 

b. Positive results of screening, when duplicated in case record:

0
 

c. Negative results of screening, when posted to summary record:

0 after posting
 

d. Negative results of screening, when notposted to summary record:

0 after individual attains age 21
  e. Blood level determination report: 10 years
  f. Summary report of screening program: PERMANENT
*6.[765] Cancer study and control program records  
 

a. Cancer case report for individual, received and used for statistical purposes:

6 years, or 3 years after individual attains age 18, whichever is longer
 

b. Cancer summary record for individual:

2 years after individual dies or attains age 90
7.[766] Negative tuberculosis X-ray films or interpretive reports resulting from screening program: 3 years
*8.[407] Individual immunization record, including authorization and/or parental consent: 6 years, or 3 years after individual attains age 18, whichever is longer
9.[408] Vaccine distribution and usage records  
  a. Official record of distribution and usage: 25 years
  b. Statistical or similar record of vaccines administered: 5 years
*10.[409] Results of screening programs, except lead poisoning  
  a. Summary reports on screening results: PERMANENT
  b. Master index or listing of participants: 50 years
 

c. Positive report of individual screened, including statement of consent or participation and authorization for release of information:

6 years, or 3 years after individual attains age 18, whichever is longer
  d. Negative report of individual screened, including statement of consent or participation and authorization for release of information: 1 year
  e. Log or other working record of screening and testing, used to compile statistics and other data: 1 year
 

f. Anonymous H.I.V. test results and related records:

NOTE: Identifiable H.I.V. related records are covered by item nos. 379 and 381, and related laboratory records are covered by items in the Laboratory subsection.

7 years
*11.[410] Receipt and storage records for controlled substances (or other drugs or medication), including inventory, authorized requisition, receipt and vendor record: 5 years
*12.[411] Usage and distribution records for controlled substances (or other drugs or medication)  
 

a. Record of withdrawal from stock, distribution and administration to patients:

5 years
  b. Order or prescription form used for administering to patients: 6 years
 

c. List of narcotic registrants (persons registered to possess or prescribe controlled substances):

0 after obsolete
  d. Report on habitual user of narcotics: 6 years
*13.[767] Tissue donation and transfer records  
  a. Master summary record (index or log) of all tissue donations and transfers: PERMANENT
  b. Reproductive tissue donation records, including but not limited to information on donor and donation, referral records, tissue storage and processing records, documentation of delivery or receipt and records of tissue disposal and/or use (other than those contained in patient medical records), of donated reproductive tissue in artificial insemination and/or assisted reproductive procedures which result in a live birth: 25 years
 

c. Reproductive tissue donation records, including but not limited to information on donor and donation, referral records, tissue storage and processing records, documentation of delivery or receipt and records of tissue disposal and/or use (other than those contained in patient medical records), of donated reproductive tissue in artificial insemination and/or assisted reproductive procedures which do not result in a live birth:

7 years after release or discard of tissue
 

d. Other tissue donation and transfer records, including but not limited to information on donor and donation, referral records, tissue storage and processing records, documentation of delivery or receipt and records of tissue disposal and/or use (other than those contained in patient medical records), for tissue intended for transplantation:

7 years after release or discard of tissue
 

e. Records of release of tissue or nontransplant anatomic parts for research or educational purposes:

5 years after release
*14.[768] Organ procurement and transplant records  
 

a. Master summary record (index or log) of all organ donations and transplants:

PERMANENT
 

b. Other organ donation and transplant records, including but not limited to information on donor and donation, referral records, documentation of delivery or receipt, information on recipient and records of use (other than those contained in patient medical records), when organ is procured:

7 years after date of procurement
 

c. Other organ donation and transplant records, including but not limited to information on donor and donation, referral records and explanation of why organ is not procured (other than those contained in patient medical records), when organ is not procured:

7 years after date of most recent entry in record
 
Last updated
Wed, 2015-10-14 15:43