ABC Hospital

Policies for Retention &

Destruction of Health Records

ABC Hospital Somewhere, Kentucky 12345

(859)-555-5555
ABCHospitalRecordsdept@ky.com
June 6, 2007- Policy# 31-10527

ABC Hospital
Contents
Introduction
Policy

Storage of Health Records

Applicable federal and state regulations for retention of Health

Records

Outline of ABC Hospital Policy Retention Standards 5

Policies on Destruction of Health Records6-8
Certificate of Health Record Destruction 9
Health Record Retention & Destruction Policy Manual
Acknowledgment

10

ABC Hospital Somewhere, Kentucky 12345

(859)-555-5555
ABCHospitalRecordsdept@ky.com
June 6, 2007- Policy# 31-10527

ABC Hospital
Introduction
ABC Hospital Health Records are a primary tool and requirement in facilitating
care for our patients. The material in this manual is designed to provide ABC
Hospital personnel with the information needed to carry out the policies and
regulations for the Retention and Destruction of Health Records.
Policy
Compliance with legal and proper Health Record retention policies is critical and
mandatory. These policies are to be strictly followed and enforced by
Administrators and personnel who have been entrusted with ABC Hospitals
Health Records. Following these policies help to ensure cost control for record
storage space, equipment and labor. It also allows ABC Hospital to achieve our
ultimate goal to meet our patients-care needs.
Storage of Health Records at ABC Hospital
Health Information Managers at ABC Hospital house all Health Records. Including
but not limited to records for all observation cases, outpatient surgery visits,
ambulatory visits, inpatient admissions, outpatient visits, and emergency
department visits
3

ABC Hospital Somewhere, Kentucky 12345

(859)-555-5555
ABCHospitalRecordsdept@ky.com
June 6, 2007- Policy# 31-10527

ABC Hospital
Applicable federal and state regulations for retention of Health Records

ABC Hospital follows policies for the Retention of Health Records in accordance
with all state and federal regulations and accreditation standards. Compliance with
state, federal and ABC Hospital policies is crucial to maintaining adequate Health
Records. The following is breakdown of the regulations for Medicare and the State
of Kentucky that are followed.

Medicare Conditions of Participation for ABC Hospital stipulates a five year

minimum of Health Record Retention.
ABC Hospital also follows the minimum for retention of Medical Records
of the State of Kentucky which states:
Adult patients
*5 years from date of discharge.
Minor patients
*5 years from date of discharge or 3 years after the patient reaches the
age of majority or until patient turns 2, whichever is longer.
Statute of limitation law dictates that ABC Hospital must retain all
Health records that pertain to an injury or crime for a minimum of ten
years
4

ABC Hospital Somewhere, Kentucky 12345

(859)-555-5555
ABCHospitalRecordsdept@ky.com
June 6, 2007- Policy# 31-10527

ABC Hospital
ABC Hospital Health Records Policy Retention Standards
Health Information
Register of births
Register of deaths
Register of surgical procedures
Master Patient/person index
Diagnostic imagesexample (x-rays, film)
Disease index
Fetal heart monitor records

Recommended Retention Period

The records are to be kept Permanently
The records are to be kept Permanently
The records are to be kept Permanently
The records are to be kept Permanently
To be kept for a minimum of 5 years after
the date of the last encounter
To be kept for a minimum of 10 years
To be kept for a minimum of 10 years after
the date the infant reaches the age of
majority
Operative index
Minimum of 10 years
Patient health/medical records for
To be kept for a minimum of 10 years after
adults
the most recent encounter for treatment
Patient health/medical records for
Kept until the minor reached the age of
minors
majority. As well as the Kentucky statute of
limitations for minors
Patients who received experimental
Kept Permanently for futures treatment
treatment
and/or research outcomes
Patients who were minors and are now Retained for a minimum of five years after
of age, but are declared incompetent
reaching age of majority
Patients in current lawsuits against the Kept Permanently
organization
Outpatient visits are kept Permanently
Ambulatory and Hospital
according to their specific clinic
-Based clinic
5

ABC Hospital Somewhere, Kentucky 12345

(859)-555-5555
ABCHospitalRecordsdept@ky.com
June 6, 2007- Policy# 31-10527

ABC Hospital
Policy on Destruction of Health Records
Destruction of records takes place only when one or more of these incidents
occur:
When retention period for a set of records has elapsed and space is
needed for current records
ABC Hospital has been sold or is/will be closing permanently
ABC Hospital is in the process of routine transfers of health records to
long-term storage
As previously stated destruction of Health records must be done in
accordance with all of ABC Hospitals policies, as well as state and federal
regulations.
Law prohibits the following records from being destroyed for any reason:
Records pertaining to an open investigation
Records that are being audited
Records that are part of a court case
6

ABC Hospital
ABC Hospital Somewhere, Kentucky 12345
(859)-555-5555
ABCHospitalRecordsdept@ky.com
June 6, 2007- Policy# 31-10527

Policy

on

Notification

to

Patients

of

Health

Record

Destruction

It is the practice of ABC Hospital to notify patients by last known address, prior to
the destruction of a health record. Notices are sent 90 days prior to the date of
scheduled destruction. This allows the patient adequate time to retrieve their
records if they so desire. All laws and policy standards of patient access to records
are applied to the retrieval of records. This included all applicable fees that are
assessed for patient records according to ABC Hospital policy.

Certificate of Destruction
ABC Hospital uses a form called Certificate of Destruction to appropriately
document the destruction of Health Records. It is a mandatory document that must
be filled out accurately any time Health Records are destroyed. The certificate of
destruction must be filed and kept permanently.
7

ABC Hospital Somewhere, Kentucky 12345

(859)-555-5555
ABCHospitalRecordsdept@ky.com
June 6, 2007- Policy# 31-10527

ABC Hospital

The Certificate of Destruction must contain the following information:

ABC Hospital Somewhere, Kentucky
12345

That date in which the record was destroyed

(859)-555-5555
ABCHospitalRecordsdept@ky.com
Exact method that was used for destruction of the Health Record
A detailed description of the record that was disposed of
Include
inclusive
dates
covered
Certificate
of Health
Record
Destruction
Documentation stating the record was destroyed in the normal course of
The Information in this document is true and accurate according to ABC Hospital retention and
destructionbusiness
policies and
procedures. The health record/records were destroyed in the normal course of
is required
business.

Any individuals who supervised or witnessed the destruction of the health

Date of Destruction:_________________

record

Inclusive dates covered:______________

Description of record/records destroyed:__________________________________________________
__________________________________________________________________________________
Method of Destruction:________________________________________________________________
8
o Burning
o Shredding
Patient Label
o Overwriting
o Pulping
o Pulverizing
o Other___________________________________________________________________

Records Destroyed By: _________________________________

Signature
Witness Signature:_____________________________________
Signature

________________________
Date
________________________
Date

ABC Hospital Somewhere, Kentucky 12345

Department Manager:___________________________________
________________________
(859)-555-5555
ABCHospitalRecordsdept@ky.com
Signature
Date
June
6, 2007- Policy# 31-10527

ABC Hospital
Health Record Retention & Destruction Policy Manual Acknowledgment

Employee Printed Name:_______________________________

Employee Signature:__________________________________

Date _________________

Department Manager Printed Name:______________________

ABC Hospital Somewhere, Kentucky 12345
Department Manager Signature:__________________________
Date ________________
(859)-555-5555
ABCHospitalRecordsdept@ky.com
June 6, 2007- Policy# 31-10527

For questions or concerns regarding ABC Hospitals Health Record Retention & Destruction Manual, please contact
Sarah J Young, Director of Medical Records Depart

10

References
UK healthcare Records (June8, 2015) A05-005, Retention and Storage of Medical Records
Farenholz, C. & Russo, R. (2013). Documentation for health records. Chicago, IL:
American Health Information Management Association.

ABC Hospital Somewhere, Kentucky 12345

(859)-555-5555
ABCHospitalRecordsdept@ky.com
June 6, 2007- Policy# 31-10527

Thomas Rhueter (2016) How Long is Long Enough?

Healthit.gov(2007): State Medical Record Laws Minimum Medical Record Retention Periods for
Records Held by Medical Doctors and Hospitals 902 Ky. Admin. Regs. 20:016

ABC Hospital Somewhere, Kentucky 12345

(859)-555-5555
ABCHospitalRecordsdept@ky.com
June 6, 2007- Policy# 31-10527