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Young Ophthalmologists
Record Retention and Destruction

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DISCLAIMER: This information is intended solely to provide risk management recommendations. It is not intended to constitute legal advice and should not be relied upon as a source for legal advice.  If legal advice is desired or needed, an attorney should be consulted. This information is not intended to be a modification of the terms and conditions of your OMIC policy of insurance. Refer to your OMIC policy for these terms and conditions.
 
While ideally records should be kept forever, this is not always practical. To ensure that present and future patient needs are adequately met, and that allegations of malpractice can be successfully defended, retain records according to the following guidelines. Once the retention guidelines have been met, the records may be destroyed.    

Retention Guidelines
  • Have a written retention and destruction policy in place, and train employees in its use. A physician must approve the policy. Indicate the date the policy was written or revised, and keep copies of former policies.
  • Consider any material related to patient care to be part of the record (such as photographs, billing records, appointment schedules, etc.).
  • Adult patients:
    • Keep 10 years after the last contact with the practice, then may destroy with physician approval.

  • Minor patients:
    • Keep 10 years after the last contact with the practice; OR
    • Four years beyond the patient’s 18th birthday, whichever is longer, then may destroy with physician approval.

  • Deceased patients: 
    • Keep five years after the patient’s death, then may destroy with physician approval.

  • Incompetent patients, whether adult or minor:
    • Retain records indefinitely; OR
    • Keep five years after the patient’s death, then may destroy with physician approval.

  • Records related to an incident that could lead to litigation or that have been requested by an attorney or administrative agency:
    • Keep until the matter has been fully resolved; AND
    • Destroy only with the advice of OMIC or your assigned attorney and physician approval. This prevents allegations of spoliation of evidence.

  • Other laws and regulations may apply in some circumstances (e.g., Medicare, OSHA, managed care patients). Check with the appropriate authority to ensure that your retention policy meets their guidelines.
Destruction of Medical Records
  • A physician must approve any decision to purge and destroy records.
  • Keep a list of destroyed records. This includes the patient’s name and birthday, the date of the last visit and the date the records were destroyed.
  • The method of destruction must protect the confidentiality of this information, such as shredding or burning. Disposing of records in the trash does not provide adequate protection, and could lead to allegations of breach of confidentiality.

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About the author: Anne M. Menke, RN, PhD, has served as risk manager for OMIC (Ophthalmic Mutual Insurance Company) since  2003. Her background includes nine years of clinical experience as a registered nurse, 15 years of teaching, research and publication at the college level and more than eight years working for physician-owned medical malpractice insurance companies in both the claims and risk management departments.