Retention of Medical Records Law

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Retention of Medical Records Law

• April 2002
• Source http//www.mag.org/generalcounsel/medical-
  records-retention0402.shtml
• Edited by Georgia CTAE Resource Network
• June 2011

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"Patient 31-33-1. Definitions

• (1) Patient means any person who has received
  health care services from a provider.

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Provider 31-33-1. Definitions

• 2) Provider means all hospitals, including
• public
• private
• osteopathic
• tuberculosis hospitals
• other special care units, including podiatric
  facilities
• skilled nursing facilities
• kidney disease treatment centers
• including freestanding
• hemodialysis units
• intermediate care facilities
• ambulatory surgical or obstetrical facilities
• health maintenance organizations
• home health agencies
• It shall also means any person licensed to
  practice under Chapter 9, 11, 26, 34, 35, or 39
  of Title 43.

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Record 31-33-1. Definitions

• (3) "Record" means a patient's health record,
  including, but not limited to
• evaluations
• diagnoses
• prognoses
• laboratory reports
• X-rays
• prescriptions, and other technical information
  used in assessing the patient's condition
• or the pertinent portion of the record relating
  to a specific condition
• or a summary of the record

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Retention of Medical Records LawApril 2002

• I. New Georgia Law on Retention of Medical
  Records.
• A provider having custody and control of any
  evaluation, diagnosis, prognosis, laboratory
  report, or biopsy slide in a patient's record
  shall retain such item for a period of not less
  than ten years from the date such item was
  created.

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General rules

• (ii) A hospital which is an institution as
  defined in subparagraph (B) of paragraph (1) of
  Code Section 31-7-1, which shall retain patient
  records in accordance with rules and regulations
  for hospitals as issued by the department
  pursuant to Code Section 31-7-2.
• Source http//law.onecle.com/georgia/31/31-33-2.h
  tml

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III. AMA Policy No. E-7.05 Retention of Medical
Records.

• Physicians have an obligation to retain patient
  records
• Which may reasonably be of value to a patient.

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The following guidelines are offered to assist
physicians in meeting their ethical and legal
obligations

• (1) Medical considerations
• The primary basis for deciding how long to retain
  medical records. For example
• Operative notes and chemotherapy records should
  always be part of the patients chart.
• In deciding whether to keep certain parts of the
  record, an appropriate criterion is Will a
  physician want the information if he or she were
  seeing the patient for the first time?
• (2) If a particular record no longer needs to be
  kept for medical reasons, the physician
• should check state laws to see if there is a
  requirement that records be kept for a minimum
  length of time.
• Most states will not have such a provision. If
  they do, it will be part of the statutory code or
  state licensing board.
• (3) In all cases, medical records
• should be kept for at least as long as
• the length of time of the statute of limitations
  for medical malpractice claims.
• The statute of limitations may be three or more
  years, depending on the state law.
• State medical associations and insurance carriers
  are the best resources for this information.

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The following guidelines are offered to assist
physicians in meeting their ethical and legal
obligations (cont)

• (4) Whatever the statute of limitations
• a physician should measure time from the last
  professional contact with the patient.
• (5) If a patient is a minor
• the statute of limitations for medical
  malpractice claims may not apply until the
  patient reaches the age of majority.
• (6) Immunization records always must be kept.
• (7) The records of any patient covered by
  Medicare or Medicaid must be kept at least five
  years.
• (8) In order to preserve confidentiality when
  discarding old records, all documents should be
  destroyed.
• (9) Before discarding old records
• patients should be given an opportunity to claim
  the records, or have them sent to another
  physician, if it is feasible to give them the
  opportunity. (Issued June 1994.)

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Additional Information Available

• Review information at this site
• http//georgiamalpractice.com/code-sol.htm

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References

• http//www.sos.ga.gov/plb/chiro/TITLE2031-20Pati
  ent20Record20Laws.pdf