What happens to a patient's/resident's medical record after death?

[Plagueis]

I'm a newly licensed LPN, and I've just been wondering about the super-heavy, thick medical records I see for each resident, and I've wondered what happens with all of the different papers that are in it in case the resident passes away.

In addition, do any of the papers ever come out of the record, such as orders, assessments, or narcotic sheets, for instance, before a resident or patient passes away? It just seems that some of those records are so large, that I would think taking papers out to make space for more would be prudent. And if any papers come out, where do they end up?

I admit that this is just one of those things-that-make-you-go-hmmm questions. :)

[caliotter3]

I read somewhere that medical records are stored for six years, so one should make sure they obtain copies of their records immediately when they change doctors or when their doctor closes their practice. One of my former doctors closed their practice (when the Medical Board snatched their license) and gave each of their patients a deadline to obtain their records before they were sent to storage. The six year timeframe was mentioned in the letter.

[elkpark]

Medical records are treated the same whether the client is discharged home or dies -- records are stored and maintained by the facility's medical records/health information department indefinitely, every single page of them (every page that is officially part of the medical record, that is), either in paper form or electronically. If an agency or facility closes down, they have to make arrangements for the records to continue to be maintained (there are companies that specialize in doing this), because interested individuals have to be able to get access to the records). Medical records are a huge deal and there are v. strict laws about what can and can't be done with them.

[elkpark]

I read somewhere that medical records are stored for six years, so one should make sure they obtain copies of their records immediately when they change doctors or when their doctor closes their practice. One of my former doctors closed their practice (when the Medical Board snatched their license) and gave each of their patients a deadline to obtain their records before they were sent to storage. The six year timeframe was mentioned in the letter.

Yes, I think the standards are a little different for physicians' private practices than they are for larger agencies.

[dishes, BSN, RN]

Good question. You can ask the health records personal at your facility what their specific guidelines. At my facility patient charts that have become full are divided into volumes.

Thick charts are thinned by removing the older flow sheets and sending them to health records. The admission history, team meetings, doctors orders, notes and consults are kept on the in-patient's chart. These particular records are not thinned because you never know when staff may need to review this information, also this information can be copied and sent with the patient in the event of an emergency transfer.

Examples of information that can be thinned include past urine output or a bowel records because it is unlikely that you need to look at this old information. If there was something unusual about these flow sheets, it likely would have been brought to the doctors attention and would be in the doctors notes.

After a client dies the chart is sealed and held in health records.

dishes

[humanity]

after a patient get discharged or deceased the medical records thin the chart that means they will keep the originall copies and shred the duplicate ones and then it goes to the machine to scan all the records and they keep the original ones forever

[CapeCodMermaid, RN]

Not really 'forever'. In Massachusetts in long term care, we are mandated to keep the entire medical record for 7 years. We usually keep them in the facility for a few years and then send them off to a giant storage unit, numbered of course in case we need to get them later. As of 2013 the regulations call for EMR for all, so the huge stacks of papers will be reduced.