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Clinical records are kept not only to document patient care, but also to assist in a physician/provider's defense should a patient bring a claim regarding that care. Without the original patient record, the defense is severely compromised. Memories fade and witnesses die, lie and innocently misrecollect.
Further, the law requires that the "best evidence" be used at trial. In a medical malpractice case, the original clinical records are the best evidence. Also, insureds may face additional claims if records are lost, destroyed or altered due to intentional acts or negligence.
Records Retention
In states where there are no specific regulations on how long patient records must be kept, SCPIE risk managers recommend retaining them indefinitely. If that's not possible, a minimum of 10 years after the last contact is recommended, although 25 years is preferable. Under no circumstances should adult patients' clinical records be retained less than 10 years following their last visit. The records of minors should be kept 10 years or until their 21st birthday, whichever is longer.
Insureds should also be aware that certain programs require clinical records to be retained for a specific time period. Additionally, contracts with insurance companies, HMOs, etc., may contain their own provisions regarding records retention. Another factor to consider is the statute of limitations on bringing a lawsuit for professional negligence, which varies from state to state.
Records Storage
Clinical records must be stored in a place and manner that maintains confidentiality. Insureds should also keep telephone and office visit logs, as lawsuits often require reconstruction of events.
If insureds cannot store old records in their offices, they can archive and store them (in bulk, if necessary) in a separate storage facility. Insureds should have control over the facility to maintain confidentiality. Other alternatives include microfilm or digitized files, which are highly effective and save a great deal of space.
Records Destruction
Before insureds destroy clinical records, they should establish documented policies and procedures for logging which ones will be destroyed, as well as when and how they will be destroyed. This can help quash any future allegations that records were destroyed deliberately and maliciously. The procedure should accomplish the following:
- Outline the length of time records will be kept.
- Define which records will be kept on-site and which off-site.
- Designate a person to be responsible for deciding
what to keep and what to purge.
- Produce a log that lists which records have been destroyed
as well as when and how.
- Provide a method of disposal (e.g., shred, pulp or incinerate)
that destroys all information in the record in order to preserve confidentiality.
It is in the insured's best interest to retain clinical records as long as possible. If the decision is made to destroy medical records after a set period of time, insureds are required to maintain the same standards of confidentiality in destroying them as they did in retaining them.
For more information about records retention, storage and destruction, contact SCPIE's Risk Management Department at 800/585-7799 or
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