Medical Records Requirements for Retention

Medical Records

Requirements for retention of medical records are more complex than many realize. Requirements may vary by state statues and federal legislation as well as by institutional policies. This paper compares regulatory requirements for Texas and California and then gives examples of how federal law can have yet another set of requirements and why institutional requirements may be longer than all legal requirements.

Under California Code Regs. tit. 22 Section 70751 - (1993) and California Code Regs. tit. 22 Section 71551- (1993), California hospitals must maintain medical records for a minimum of seven years following patient discharge, except for minors (Practice brief - retention of health information). Records of minors must be maintained for at least one year after a minor has reached age 18, but in no event for less than seven years (Practice brief - retention of health information). Various California regulations extend this requirement to acute psychiatric hospitals, skilled nursing facilities, intermediate care facilities, home health agencies, primary care clinics psychology clinics and psychiatric facilities (Practice brief - retention of health information).

Texas Health and Safety Code Section 241.103, states that hospitals may dispose of medical records on or after the 10th anniversary of the date on which the patient was last treated in the hospital (Practice brief - retention of health information), thus requiring three more years of retention than California. If the patient was under age 18 when last treated, the hospital may dispose of the records on or after the patient's 20th birthday or on or after the 10th anniversary of the date on which the patient was last treated, whichever is later (Practice brief - retention of health information). Thus, Texas also requires three more years of retention for the records of minors than does California, and protects the minor for two years rather than one year after a minor has reached age 18. Texas law also adds the stipulation that a hospital may not destroy medical records that relate to any matter that is involved in litigation if the hospital knows the litigation has not been resolved (Practice brief - retention of health information).

Federal laws for record retention often are different from state laws. For instance, hospitals that participate in Medicare must keep medical records on each inpatient and outpatient, records of radiologic service, nuclear medicine including records for the receipt and disposition of radipaharmaceutics for five years. (42 CFR 482.24,.26, and.53) (Calloway). Further, psychiatric hospitals that participate in Medicare must maintain special records including development of assessment/diagnostic data, treatment plan, record progress, discharge planning, and discharge summary for 5 years (Calloway). Thus, Medicare record retention requirements are two years less than those in California and three years less than those in Texas in these instances, facilities would need to follow the longer retention requirements of their respective state.