Retention of medical records

Created: May 1, 1998
Modified:
May 2009; Reviewed July 2013

Licensees have both a legal and ethical obligation to retain patient records.  The Board, therefore, recognizes the necessity and importance of a licensee’s proper maintenance, retention, and disposition of medical records.  The following guidelines are offered to assist licensees in meeting their ethical and legal obligations: 

  • State and federal laws require that records be kept for a minimum length of time including but not limited to:
    1. Medicare and Medicaid Investigations (up to 7 years);
    2. HIPAA (up to 6 years);
    3. Medical Malpractice (varies depending on the case but should be measured from the date of the last professional contact with the patient)—licensees should check with their medical malpractice insurer);
    4. North Carolina has no statute relating specifically to the retention of medical records;
    5. Immunization records always must be kept.
  • In addition to existing state and federal laws, medical considerations may also provide the basis for deciding how long to retain medical records.  Patients should be notified regarding how long the licensee will retain medical records.
  • In deciding whether to keep certain parts of the record, an appropriate criterion is whether a licensee would want the information if he or she were seeing the patient for the first time.  The Board, therefore, recognizes that the retention policies of licensees giving one-time, brief episodic care may differ from those of licensees providing continuing care for patients.
  • In order to preserve confidentiality when discarding old records, all records should be destroyed, including both paper and electronic medical records.
  • Those licensees providing episodic care should attempt to provide a copy of the patient’s record to the patient, the patient’s primary care provider, or, if applicable, the referring licensee.
  • If it is feasible, patients should be given an opportunity to claim the records or have them sent to another licensee before old records are discarded.
  • The licensee should respond in a timely manner to requests from patients for copies of their medical records or to access to their medical records.
  • Licensees should notify patients of the amount, and under what circumstances, the licensee will charge for copies of a patient’s medical record, keeping in mind that N.C. Gen. Stat. 90-411 provides limits on the fee a licensee can charge for copying of medical records.

 

1 LIcensees should retain medical records as long as needed not only to serve and protect patients, but also to protect themselves against adverse actions.  The times stated may fall below the community standard for retention in their communities and practice settings and for the specific needs.  LIcensees are encouraged (may want to) seek advice from private counsel and/or their malpractice insurance carrier.


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