Retention of Medical Records Law

1. Retention of Medical Records Law April 2002 Source: http://www.mag.org/generalcounsel/medical-records-retention0402.shtml Placed in slide presentation format

2. "Patient“§ 31-33-1. Definitions • (1) “ Patient”means any person who has received health care services from a provider.

3. “Provider” § 31-33-1. Definitions • 2) “Provider” means all hospitals, • including public, • private, • osteopathic, • and tuberculosis hospitals; • other special care units, including podiatric facilities, • Skilled nursing facilities, • and kidney disease treatment centers, • including freestanding • hemodialysis units; • intermediate care facilities; • ambulatory surgical or obstetrical facilities; • health maintenance organizations; and • home health agencies. • It shall also means any person licensed to practice under Chapter 9, 11, 26, 34, 35, or 39 of Title 43.

4. “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.

5. Retention of Medical Records LawApril 2002 • I. New Georgia Law on Retention of Medical Records. • A provider have custody, control and retain item in a patient's record for a period of not less than ten years from the date such item was created for items such as: • of any evaluation, • diagnosis, • prognosis, • laboratory report, • or biopsy slide (a)(1)(A) • In Georgia(USA) medical records should be kept on file at a physicians office for at least 10 years after the last visit.

6. 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.html

7. 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. • 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 patient’s 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?

8. AMA Policy No. E-7.05 Retention of Medical Records.(Cont’d) • (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.

9. III. AMA Policy No. E-7.05 Retention of Medical Records. (cont’d) • (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.

10. III. AMA Policy No. E-7.05 Retention of Medical Records. (cont’d) • (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.)

11. Additional Information Available • Review information at this site: • http://georgiamalpractice.com/code-sol.htm

12. References: • http://www.enotes.com/law/q-and-a/what-statute-limitations-georgia-regarding-how-76289 • http://www.sos.ga.gov/plb/chiro/TITLE%2031-%20Patient%20Record%20Laws.pdf