Records Retention and Disposition Schedule MU-1

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RETENTION:        7 years after superseded, revoked, or no longer valid

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

Appointment records, including slips, return cards, sign-in sheets, and clinic schedules kept by facility or public health program:
RETENTION:        0 after obsolete

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

Screening and assessment records and referrals, for persons evaluated but not treated by facility or program:
RETENTION:        3 years

a.       When person involved is or becomes a patient:
RETENTION:        Retain as long as patient case record

b.       When person involved is not or does not become a patient:
RETENTION:        6 months

Annual expenditure report or budget submitted to State or Federal agency or professional review organization:
RETENTION:        PERMANENT

a.       Individual case record, account card, or ledger card:
RETENTION:        7 years after account closed, but not less than 9 years

b.       Individual charge records, posted to case record or card:
RETENTION:        7 years

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:
RETENTION:        7 years

Insurance and reimbursement related reports, including Medicare/Medicaid cost report and certified uniform financial or statistical report, and all necessary supporting documentation:
RETENTION:        9 years

Patient personal property records, including log or register of personal property of patients and receipts and related property records of original entry:
RETENTION:        6 years after death or discharge of patient

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

b.       Memoranda, routine correspondence, and supplemental fiscal documentation:
RETENTION:        6 years after last entry

a.       Minutes of medical staff committees, including but not limited to utilization review committee, joint conference committee or patient care conference:
RETENTION:        PERMANENT

b.       Records of medical staff committees, excluding minutes, including but not limited to agenda, worksheets and notes:
RETENTION:        6 years

c.       Minutes and all other records of facility committee other than medical staff committees, such as dietary services committee or activities committee:
RETENTION:        6 years

a.       Food service records, including meal counts, roster of patients' diet orders, and dietary services studies:
RETENTION:        3 years

b.       Menus:
RETENTION:        1 year

Patient activities records, including information on courses and activities offered to patients: 
RETENTION:        2 years

Medical information index, including but not limited to physician's index, disease index and operative index:
RETENTION:        PERMANENT

Census record of patients:
RETENTION:        6 years

Nursing services report, including substation, shift and ward report:
RETENTION:        1 year

a.       Request for data or review of data:
RETENTION:        2 years

b.       Results of data processing:
RETENTION:        0 after data verified

c.       Data received from S.P.A.R.C.S.:
RETENTION:        0 after no longer needed for administrative purposes

a.       Quality assurance plan, including staff privileges review procedures:
RETENTION:        PERMANENT

b.       Relating to quality of care provided by individual hospital staff members:
RETENTION:        10 years after termination of employment

c.       Relating to quality of care provided individual patient, when not duplicated in medical case record:
RETENTION:        Retain as long as medical case record

d.       Relating to more than one patient:
RETENTION:        Retain as long as all relevant medical case records are retained

Health facility infection control and monitoring records:
RETENTION:        10 years

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

Patient data file, providing summary and/or detailed information on patient:
RETENTION:        Maintain as long as patient medical or other case record

NOTE: 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. 415, above).  Contact SARA for additional advice.

Patient's leave records, including leave book or slip, patient's request, physician's consent and record of leave taken:
RETENTION:        6 years

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

a.       When person is not admitted:
RETENTION:        0 after obsolete

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

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:
RETENTION:        6 years after death or discharge of patient, but not until 3 years after individual attains age 18

NOTE:  Appraise these records for historical significance.  These records may have continuing value for historical or other research, and SARA 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.  SARA 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.

Medical case record of long-term care health facility patient:
RETENTION:        6 years after death or discharge of patient, but not until 3 years after individual attains age 18

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:
RETENTION:        6 years after discharge or last contact, but not until 3 years after youngest patient attains age 18

a.       When significant information is posted to medical case record:
RETENTION:        6 years

b.       When significant information is not posted to medical case record:
RETENTION:        Retain as long as medical case record

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, 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. 417, above) must be retained for 10 years pursuant to requirements found in 21 CFR, Section 900.12 (e-1).  Consult your attorney or counsel to determine what action is necessary to meet this requirement.

a.       When significant information is posted to medical case record:
RETENTION:        0 after posting

b.       When significant information is not posted to medical case record:
RETENTION:        Retain as long as medical case record

a.       Communicable disease case report or equivalent record, including copy of laboratory report: 
RETENTION:        6 years after discharge or last contact, or 3 years after individual attains age 18, 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 3 years after individual attains age 18, whichever is longer

Mental health incident report:
RETENTION:        20 years

a.       Clinical discharge summary:
RETENTION:        25 years

b.       Psychiatric test answer sheets:
RETENTION:        6 years

c.       Case record materials, except clinical discharge summary and psychiatric test answer sheets:
RETENTION:        10 years after discharge or last contact with patient, or 3 years after individual attains age 18, whichever is longer

NOTE:  Appraise these records for historical significance.  Records covered by item nos. 443 & 444 may have continuing value for historical or other research.  Contact SARA for additional advice in this area.

Alcohol or substance abuse individual case record including clinical discharge summary:
RETENTION:        6 years after date of discharge or last contact, or 3 years after individual attains age 18, or for the period required by contractual arrangements, whichever is longest

a.       Reports, studies or queries relating to individual patient:
RETENTION:        Retain as long as or as part of medical or other patient case record

b.       Reports, studies or queries not relating to individual patient:
RETENTION:        0 after no longer needed

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 SARA for additional advice.

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 SARA for additional advice.

b.       Record of collection of specimens:
RETENTION:        7 years

a.       For clinical laboratory tests:
RETENTION:        Maintain as long as related laboratory tests results

b.       For forensic or toxicology tests:
RETENTION:        6 years

c.       For environmental health tests:
RETENTION:        Maintain as long as related laboratory tests results

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. 445, above).  Contact SARA for additional advice.

Request for laboratory test:
RETENTION:        Retain as long as the related test results or 7 years, whichever is shorter

Referral information for cytogenetic cases:
RETENTION:        6 years

a.       For environmental health, or toxicology or forensic test:
RETENTION:        Retain as long as related test results

b.       For clinical laboratory tests:
RETENTION:        1 year

Preventive maintenance, service, or repair record for laboratory equipment or instrument:
RETENTION:        Retain as long as the equipment or instrument remains in use, and also as long as test results using this equipment are retained

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.

Quality control records covering laboratory equipment and procedures:
RETENTION:        Retain as long as test results using this equipment are retained, but not less than 2 years

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.

Laboratory protocol detailing procedures for conducting tests, disposing of specimens, samples and supplies, or other activity, including superseded or obsolete procedures:
RETENTION:        PERMANENT

Laboratory reports, studies or data queries, including those generated from automated data system

a.       Forensic and other related investigation reports:
RETENTION:        6 years

b.       All other reports, studies or queries:
RETENTION:        0 after no longer needed

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 SARA for additional advice.

Laboratory specimens and slides

a.       Blood film, routine:
RETENTION:        6 months

b.       Blood film, other than routine:
RETENTION:        1 year

c.       Cytology slide, showing abnormality:
RETENTION:        7 years

d.       Cytology slide, showing no abnormality:
RETENTION:        3 years

e.       Bone marrow biopsy, tissue block, and histopathology slide:
RETENTION:        20 years

f.        Bacteriology slide, on which no diagnosis depends:
RETENTION:        0

g.       Bacteriology slide, on which a diagnosis depends:
RETENTION:        1 year

h.       Cytogenetic slide: 
RETENTION:        6 years

i.        Photographic record of cytogenetic karyotype:
RETENTION:        25 years

j.        Recipient blood specimens:
RETENTION:        1 week

a.       When plasmapheresis, cytapheresis, intraoperative and postoperative blood recovery, isovolemic hemodilution or reinfusion is involved:
RETENTION:        7 years after procedure involved

b.       Other blood related records, including autogenic or allogenic transfusions:
RETENTION:        7 years, or 6 months after the expiration date of the individual product, whichever is later

a.       Detailed delivery record:
RETENTION:        2 years

b.       Summary record of receipt and distribution:
RETENTION:        5 years

a.       Notification of establishment or discontinuance of station or of appointment or termination of its caretaker:
RETENTION:        PERMANENT

b.       Certificate of approval of station maintenance:
RETENTION:        2 years  

c.       Periodic inventory of station supplies:
RETENTION:        6 years

a.       Positive report of syphilis serology:
RETENTION:        7 years

b.       Negative report of syphilis serology:
RETENTION:        2 years

c.       Tissue pathology (including exfoliate cytology) report:
RETENTION:        20 years

d.       Cytogenetics report:
RETENTION:        25 years

e.       Clinical, except those listed above:
RETENTION:        7 years

Forensic and toxicology test results:
RETENTION:        6 years

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.

a.       Chemical analysis of potable water supply:
RETENTION:        10 years

b.       Routine analysis of water at pool or beach:
RETENTION:        0 after posted to summary record, or 3 years if not posted

c.       All other environmental health test results:
RETENTION:        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:
RETENTION:        12 years

e.       Local health agency copy of any environmental analysis received from laboratory:
RETENTION:        1 year

a.       Approval to possess or use radioactive materials, received from New York State Department of Health, and related records:
RETENTION:        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:
RETENTION:        2 years after expiration or renewal

a.       Records of diagnostic misadministrations:
RETENTION:        3 years

b.       Records of therapeutic misadministrations:
RETENTION:        6 years

c.       Radiation-exposure data for an individual, including records of radioactive material deposited or retained in body:
RETENTION:        0 after individual attains age 90

a.       Annual or other summary occupational dose records:
RETENTION:        0 after individual attains age 90

b.       Detailed occupational dose records:
RETENTION:        0 after annual or other summary record containing this information is produced

c.       Records of prior occupational dose:
RETENTION:        0 after individual attains age 90

d.       Records of planned special exposures:
RETENTION:        0 after individual attains age 90

a.       Regulatory inspection and audit records, including master summary record and "index card":
RETENTION:        6 years after equipment no longer in use

b.       Equipment accuracy testing records, including surveys, calibrations, measurements, and quality control tests:
RETENTION:        3 years

a.       Records concerning theft or loss of radiation source, excessive release of radiation, or excessive exposure of individual to radiation, including documentation of notification:
RETENTION:        PERMANENT

b.       Record of disposal by burial in soil:
RETENTION:        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:
RETENTION:        6 years

a.       Records documenting provisions of program:
RETENTION:        3 years after program ceases to exist

b.       Audits and other reviews of program content and implementation:
RETENTION:        3 years

c.       Records documenting specific instructions given to workers:
RETENTION:        3 years

Birth and death records held by health agency or facility, including copies of birth and death certificates, and related electronic records:
RETENTION:        0 after no longer needed

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 Chapter 809, Laws of 1987.

NOTE:  This item does not cover official copies of birth and death certificates held by the health departments of Chemung, Monroe, Onondaga and Tompkins counties, which serve as registrars of vital statistics.

Medical rehabilitation service card:
RETENTION:        6 months after completion of annual report

a.       Dental hygienist's clinic record:
RETENTION:        0 after youngest person on record attains age 21

b.       Dental referral card, notifying clinic of work done by private dentist:
RETENTION:        2 years

c.       Individual dental treatment summary record:
RETENTION:        6 years after dental work completed, or 3 years after individual attains age 18, whichever is longer

Nutrition program eligibility and certification records (including W.I.C. program), including but not limited to copy of blood test results, record of advice given patient, and records of fair hearing procedure:
RETENTION:        6 years after last entry

a.       Clinic service report, including but not limited to school health service report, and report of poisoning case, except lead poisoning:
RETENTION:        1 year

b.       Individual newborn infant metabolic defects screening report:
RETENTION:        0 after individual attains age 21

Housing investigation case record for lead poisoning:
RETENTION:        7 years after case closed

Master summary record (index, log, register or similar record) of lead poisoning cases and investigations:
RETENTION:        PERMANENT

a.       Positive results of screening, when not duplicated in case record:
RETENTION:        Retain as long as case record

b.       Positive results of screening, when duplicated in case record:
RETENTION:        0

c.       Negative results of screening, when posted to summary record:
RETENTION:        0 after posting

d.       Negative results of screening, when not posted to summary record:
RETENTION:        0 after individual attains age 21

e.       Blood level determination report:
RETENTION:        10 years

f.        Summary report of screening program:
RETENTION:        PERMANENT

a.       Cancer case report for individual, received and used for statistical purposes:
RETENTION:        6 years, or 3 years after individual attains age 18, whichever is longer

b.       Cancer summary record for individual:
RETENTION:        2 years after individual dies or attains age 90

a.       When individual has died:
RETENTION:        3 years after death

b.       When individual's diagnosis has been changed to nontubercular:
RETENTION:        6 years after diagnosis changed

c.       For other tubercular individual:
RETENTION:        20 years after last entry

d.       For nontubercular contact:
RETENTION:        6 years, or 3 years after individual attains age 18, whichever is longer

e.       Source or intermediary documents used in reporting, tracking or posting information on tubercular cases: 
RETENTION:        0 after obsolete

Tuberculosis case listing by geographical area:
RETENTION:        0 after superseded or obsolete

Negative tuberculosis X-ray films or interpretive reports resulting from screening program:
RETENTION:        3 years

Individual immunization record, including authorization and/or parental consent:
RETENTION:        6 years, or 3 years after individual attains age 18, whichever is longer

a.       Official record of distribution and usage:
RETENTION:        25 years

b.       Statistical or similar record of vaccines administered:
RETENTION:        5 years

a.       Summary reports on screening results:
RETENTION:        PERMANENT

b.       Master index or listing of participants:
RETENTION:        50 years

c.       Positive report of individual screened, including statement of consent or participation and authorization for release of information:
RETENTION:        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:
RETENTION:        1 year

e.       Log or other working record of screening and testing, used to compile statistics and other data:
RETENTION:        1 year

f.        Anonymous H.I.V. test results and related records:
RETENTION:        7 years

NOTE: Identifiable H.I.V. related records are covered by items 436 and 438, and related laboratory records are covered by items in the Laboratory subsection.

Receipt and storage records for controlled substances (or other drugs or medication), including inventory, authorized requisition, receipt and vendor record:
RETENTION:        5 years

a.       Record of withdrawal from stock, distribution and administration to patients:
RETENTION:        5 years

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

c.       List of narcotic registrants (persons registered to possess or prescribe controlled substances):
RETENTION:        0 after obsolete

d.       Report on habitual user of narcotics:
RETENTION:        6 years

  a.       Master summary record (index or log) of all tissue donations and transfers:
RETENTION:        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:
RETENTION:        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:
RETENTION:        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:
RETENTION:        7 years after release or discard of tissue

e.       Records of release of tissue or nontransplant anatomic parts for research or educational purposes:
RETENTION:        5 years after release

a.       Master summary record (index or log) of all organ donations and transplants:
RETENTION:        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:
RETENTION:        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:
RETENTION:        7 years after date of most recent entry in record

Copies of laboratory reports, submitted to health department by hospitals for informational purposes:
RETENTION:        0

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 date waste destroyed

c.       Annual reports prepared by waste generator or transporter:
RETENTION:        3 years