Health Records, Module 3, Ch.

Health Records Retention and Destruction Policy

Medical Records Department, ABC Hospital

Purpose: To establish a formal policy for the retention and destruction of health
records and to define the schedule and procedures for destruction of health records.

Scope: This policy applies to all employees of ABC Hospital.

Responsibility: Clinicians, Medical Records Staff, and all ABC Hospital Staff with
access to health records.

Retention of Health Records

ABC Hospital must retain all patient health records according to accepted
professional standards and practices. Per Health Information & the Law Project, as
a condition of licensure, the following facilities and programs must maintain medical
records for every patient for the designated time period. Each health care
facility must maintain records for six years from the date of discharge, documenting
the patients needs and assessments and services rendered. The provider of a
health care service must maintain records for five years from the date of discharge;
such record must document the patients needs and assessments and services
rendered. Each residential care facility must maintain records for seven years
following the date of the residents discharge. Every nursing home must maintain
records for seven years following the date of the residents discharge. Each
freestanding or mobile diagnostic imaging center must maintain all records for six
years from the date of service. Adult care facilities must maintain a record for two
years after the resident is permanently transferred, discharged, or dies (2012). Per
the Centers for Medicare & Medicaid Services, the Health Insurance Portability and
Accountability Act (HIPAA) of 1996 (HIPAA) administrative simplification rules require
a covered entity, such as a physician billing Medicare, to retain required
documentation for six years from the date of its creation or the date when it last
was in effect, whichever is later (2010).
The following chart, provided by Lisa Patenaude in HCN Healthcare News
(2007) is a general rule of thumb for health record retention:
Record Type
Retention Period
Patient medical records
* 10 years from last visit
Encounter forms
5 years
Pathology slides, EEG, ECG tracings
10 years
Lab reports (positive readings)
5 years
Insurance claim forms, EOBs
5 years
X-ray films
5 years
Annual billing and productivity reports
5 years
* Note: Generally, for pediatric and ob/gyn practices, records should be retained for
at least 10 years after the child attains adult legal status.
These guidelines apply equally to hard copy and electronic medical records.

Health Records, Module 3, Ch. 3

While these are just a general rule of thumb, it is safest to follow the longest
required retention period in the event that several apply.

Destruction of Health Records

ABC Hospital will destroy health records once they exceed the mandated
retention period. Prior to any records or documents being destroyed, the Medical
Records Supervisor must review and approve all documents for destruction to
ensure that the record and/or document is no longer needed by the facility for any
legal, fiscal, administrative, or archival reasons (Destruction of medical/Dental
records Protocol, 2016).
AHIMA (2013) provides the following examples of destruction methods:
Paper record methods of destruction include burning, shredding, pulping, and
pulverizing
Microfilm or microfiche methods of destruction include recycling and
pulverizing
Laser discs used in write once-read many document-imaging applications are
destroyed by pulverizing
Computerized data are destroyed by magnetic degaussing
DVDs are destroyed by shredding or cutting
Magnetic tapes are destroyed by demagnetizing
Prior to destruction of any health record, ABC Hospital must create a permanent
record destruction log. This log must list the following information according to
AHIMA (2013):
Date of destruction
Method of destruction
Description of the disposed records
Inclusive dates
A statement that the records were destroyed in the normal course of business
The signatures of the individuals supervising and witnessing the destruction
Under the HIPAA privacy rule, if/when ABC Hospital outsources the destruction of
health records to a specialized company, the contract must provide that the
business associate will establish the permitted and required used and disclosures
and include the following elements:
The method of destruction or disposal
The time that will elapse between acquisition and destruction or disposal
Safeguards against breaches
Indemnification for the organization or provide for loss due to unauthorized
disclosure
Require the business associate to maintain liability insurance in specified
amounts at all times (AHIMA, 2013).

Health Records, Module 3, Ch. 3

Works Cited
AHIMA. "Retention and Destruction of Health Information." (Updated October 2013).
Centers for Medicare & Medicaid Services. (2010, August 23). Medical Record
Retention and Media Formats for Medical Records. Retrieved September 7,
2016, from MLN Matters: https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE1022.pdf
Health Information & the Law Project. (2012). Medical Records Collection, Retention,
and Access in Ohio. Retrieved September 7, 2016, from Health Information &
the Law Project: http://www.healthinfolaw.org/state-topics/36,60/f_topics
Patenaude, L. (2007, October). Records Retention and Destruction It's Important to
Have Firm Policies in Place. Retrieved September 7, 2016, from HCN
Healthcare News: http://healthcarenews.com/records-retention-anddestruction-its-important-to-have-firm-policies-in-place/
U.S. Department of Health and Human Services. (2016). Destruction of
medical/Dental records Protocol. Retrieved September 7, 2016, from HRSA
Health Center Program:
http://bphc.hrsa.gov/archive/technicalassistance/resourcecenter/services/dest
ructionofnedicalrecordprotcol.pdf
U.S. Department of Health and Human Services. (2016). Medical Records Policy.
Retrieved September 7, 2016, from HRSA Health Center Program:
http://bphc.hrsa.gov/archive/technicalassistance/resourcecenter/clinicalservic
es/medicalrecordspolicy.pdf