Medical charts- do hospitals keep them?
- 0May 18, '07 by changeofpaceRNDoes anyone know? If so, for how long? I thought it was law to keep charts right?
- 0May 18, '07 by kukukajooOh no- the law states 7 years if I remember right and in some cases it may be five. If you have old records somewhere that you may need- go get them now and take them with you.
I recently went to get old CT scans and Xrays, etc and they were destroyed almost 7 years to the date even though I had been a pt there since. They were needed to show progression of a chronic problem and there is no baseline to compare with.
- 0May 18, '07 by P_RN Senior ModeratorI believe our med. rec were sent to Atlanta for "storage" after about 2 years. I know that after about 5 all that is left is the admission & disch summary and the face sheet. So far I've been able to get copies of most of my important radiology "films" but now they're digital I don't know how they'll handle that.
- 0May 19, '07 by hollyvkSteve Case (former CEO of AOL/American Online) has started a new business that includes the ablility to store YOUR medical records online (then available with your assistance to any of your healthcare providers):
I work in healthcare infomatics and I predict that in the next 5 years we are going to see a HUGE push towards all electronic medical records. And what patient wouldn't want to be in charge of their own medical record storage?
HollyVK RN, BSN, JD
- 0May 19, '07 by Daytonitei am an rn who is back in school studying for a degree in health information management (medical records). the answer to your question is yes. hospitals do keep medical records. it is mandated by both federal and usually state law.
the specific federal law on this is in title 42 (medicare conditions of participation). 42 cfr 482.24 condition of participation: medical record services. (b) standard: form and retention of record. and it says: the hospital must maintain a medical record for each inpatient and outpatient. medical records must be accurately written, promptly completed, properly filed and retained, and accessible. the hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. (1) medical records must be retained in their original or legally reproduced form for a period of at least 5 years.
i searched through chapter 395 of title xxix of the florida statutes and couldn't find anything specific on the retention of hospital medical records. in searching i did find this article, but it also does not give any specific information on florida law with regard to retention of medical records in your state: http://library.findlaw.com/1998/jan/1/127216.html
if the answer to this question is burning in your mind, someone in the medical records department, preferably an hrit (health records information technician, this is a certified designation), will know the answer. otherwise, the federal law of 5 years that i've listed above would apply. my state of california has specific retention requirements for the medical records of children that have to do with them reaching the age of majority, so their medical records are often retained for a longer period of time to preserve their legal right to bring a lawsuit when they reach the age of 18 for some medical malpractice that may have occurred to them as babies or children. you might want to ask about something like that in your state as well.
a big change is going to occur in medical records in the future. the medical record is going to go electronic. i can also tell you from my own experiences that hospitals will destroy medical records after a certain period of time. i tried to get old radiation therapy records of mine when a complication came about, but was too late. they were too old and had already been destroyed. we all have the right to obtain copies of most of the information that is in our hospital records. it would be a very smart idea to start your own file and keep copies of x-rays, ct scans, mris, surgical reports, consults and any other information that you think might be important long into the future. and, as i recently discovered when my elderly mom became ill, you may find yourself in the position of having to do this for your parents or someone else you are responsible to care for. the american health information association has set up an educational website for the general public where you can learn about medical records and how to get started on keeping your own: http://www.myphr.com/
medical records department is no longer that small office in the corner of the basement. they do a heck of a lot more than you could possibly imagine.
- 0May 20, '07 by mshultzOnce upon a time:
1. I thought medical records were kept until you died.
2. When you moved and changed doctors, your old records were automatically forwarded to the new doctor.
3. That all of your healthcare providers had access to all of your records.
4. If you just wished hard enough, Tinkerbell would live
Daytonite is right! The only way you can be sure of having a complete medical record is to have your own copies. I requested a complete copy of my hospital records in 2004 (I was hospitalized in 2003). I did not receive my x-rays, and the colonoscopy image was a black and white photocopy, instead of a color print.
Since I could not figure out the proper way of requesting these images, I Emailed the patient advocate this year, and was directed to fill out another medical records request. Page 2 of a doctor's report arrived in the mail (it had been missing, so I asked for it, also). The note said the x-ray images were on the way, but that the colonoscopy image was only saved as microfilm
I had been told by a hospital employee at a health fair that x-ray images are only kept for 5 years. The hospital is also in the process of converting film x-ray images to digital, so maybe they sent me the originals. At any rate, I have not been billed for this additional request. It could also be that I had them dead to rights, since the original request ($30) did have the word "everything" on it.
So, it would seem that if you want color images from endoscopic procedures, you need to tell them in advance. I had naively assumed that since I was offered pictures of my EGD (and said Yes), the same doctor would offer me picture(s) of my colonoscopy. This colonoscopy picture, which was normal, would have saved an hour of anxiety, since I was too gorked to remember his talk, which he did immediately after the colonoscopy.
- 0May 21, '07 by mommy2boysQuote from P_RNIf your films are digital, they can print them off and they look like regular films. I had to have a CT scan and my Urologist doesn't have the tech. to see the digital films so they printed off the films for me to hand deliver.I believe our med. rec were sent to Atlanta for "storage" after about 2 years. I know that after about 5 all that is left is the admission & disch summary and the face sheet. So far I've been able to get copies of most of my important radiology "films" but now they're digital I don't know how they'll handle that.
- 0May 21, '07 by hollyvkVerizon Communications has announced that it has implemented a personal health record (PHR) system for its more than 900,000 active employees, retirees and their families. The system, Verizon HealthZone, integrates with WebMD to allow members to store personal health information on a password-protected Web site.
- 0May 26, '07 by ZippyGBRQuote from P_RNI believe our med. rec were sent to Atlanta for "storage" after about 2 years. I know that after about 5 all that is left is the admission & disch summary and the face sheet. So far I've been able to get copies of most of my important radiology "films" but now they're digital I don't know how they'll handle that.
there are two financial reasons for going over the digital radiography
1. reduced spend on film and chemicals
2. reduced spend on storage - several large store rooms are replaced by a broom closet sized server room
the clinical benefits are secondary in the eyes of the damagement but they are good to sell the idea to clinicians