ABC Hospital

Diana Reed
Director of Medical Records

POLICY FOR THE RETENTION AND

DESTRUCTION OF HEALTH RECORDS
PURPOSE
The purpose of this policy is to ensure that all necessary health records and documents of
ABC Hospital are kept in compliance with all applicable state and federal regulations,
accreditation standards, as well as meeting future patient-care needs. This policy also serves
to ensure that records that have surpassed their need or are no longer valued by ABC
Hospital are destroyed in accordance with all relevant regulations and standards.

POLICY
ABC Hospital will protect the privacy of all protected health information (PHI) and retain
these documents in whatever format they are storedpaper, electronic, or a hybrid system.
Further, when necessary to destroy or dispose of these documents, ABC Hospital will destroy
such records in accordance with all applicable local, state, and federal regulations.

EFFECTIVE DATE
June 2014

PROCEDURE
I.

ADMINISTRATION

This policy will apply to all health records generated by ABC Hospital while providing patient
care in any setting of said Hospital. All hospital personnel who use or have access to health
records are responsible for ensuring the maintenance, storage, retention, and destruction of
said documents in accordance with all applicable state and federal laws, as well as all
regulatory and accreditation standards. The Director of Medical Records is in charge of
administration of this policy and ensuring that the record retention schedules and
destruction policies laid out herein are met. The Director of Medical records is also
authorized to monitor said policy and, when necessary, update and amend the policy to
ensure all local, state, and federal laws as well as accreditation and regulatory standards are
being met.

II.

RETENTION

Health records will be kept according to the retention schedule and may take the form of:

Paper documents

Policy for Retention and

Destruction of Health Records

ABC HOSPITAL

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Electronic documents
Micrographic film
Physical or scanned images
Video and audio files
CD or optical discs
Magnetic tapes

RETENTION SCHEDULE
TABLE 1. RETENTION SCHEDULE FOR HEALTH RECORDS

RECORD TYPE
Admissions/discharge register
Diagnostic images (e.g., X-rays, MRIs)
Disease index
Fetal heart monitor records
End Stage Renal disease (ESRD)
services
Laboratory records
Mammography services
Master patient index
Operative index
Patient medical records (adults)
Patient medical records (minors)
Physician index
Registers of births and deaths
Register of surgical procedures

III.

RETENTION PERIOD
Permanently
5 years
10 years
10 years after the infant reaches the age of
majority
6 years after discharge, transfer or death of
patient
10 years
10 years
Permanently
10 years
10 years
Age of majority plus statute of limitations
10 years
Permanently
Permanently

DESTRUCTION

ABC Hospital may destroy all health records at the end of their retention periodpending
those documents involved in any legal claim or actionand maintain all applicable
standards and regulations in doing so. ABC Hospital will notify patients one (1) year before
scheduled destruction of records to allow patients time to request copies of their health
records. Records will be destroyed according to document type as follows:

Paper documents burning, shredding, pulping or pulverizing

Micrographic films recycling or pulverizing
CD or optical disc shredding or pulverizing
Electronic documents magnetic degaussing
Magnetic tapes magnetic degaussing or zeroization process

ABC Hospital will maintain documentation for all permanently destroyed health records
which will include the following information:

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

Policy for Retention and

Destruction of Health Records

ABC HOSPITAL

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In the event ABC Hospital contracts out the destruction of health records, said contract must
meet the standards set forth in the HIPPA Privacy Rule.

IV.

LITIGATION

In the event of legal action or claim requesting any health record held by ABC Hospital, all
retention and destruction schedules for those documents shall be suspended until such a
time as the legal request or claim has passed. At this time all documents may return to their
previous retention and destruction schedule.

REFERENCES
(n.d.). Retention and Destruction of Records. Retrieved September 09, 2016, from
https://www.nyu.edu/about/policies-guidelines-compliance/policies-andguidelines/retention-and-destruction-of-records.html
Downing, K., & Pye, M. (2013). Retention and destruction of health information (2013
update).
Retention and Destruction of Health Information (2013 Update) / AHIMA,
American
Health Information Management Association, Retrieved from
http://library.ahima.org/doc?oid=107114

Policy for Retention and

Destruction of Health Records

ABC HOSPITAL

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