General practitioners have lots of responsibilities regarding maintaining of medical records. The length of time a doctor is supposed to retain medical reports vary from states to states depending with federal and state laws, type of medical report, medical board. Furthermore we have reasons as to why physicians should keep medical report. The major reason is to avail information to other medical professionals on patient’s care and also in case of medical misconduct it can be used in defense. In absence of medical record, the medical doctor may not be in position to prove that the medical care given was suitable and was in accordance with the standard of care (Dixon 2007, 2). The state and federal laws with respect to compulsory medical records retention time limits concerns hospital facilities rather than medical doctor’s clinic. In this study we will discuss California State and Alabama. We first discuss retention time limits in California and then Alabama.
California Statutory Medical Records Retention Periods
California statutory administration which exclusively regulates general practitioner’s retention of medical records is found among the following: the Medical Conditions of Participation (COP) necessitate hospital facilities to keep records for a period of five years for general hospitals and six years for critical access infirmaries. While Occupational Safety and Health Act (OSHA ) which pertain to definite documentations of employees exposed to poisonous substances calls for medical records being maintained for no less than the period of employment in addition with thirty years.
The Health Insurance Portability and Accountability Act (HIPAA) privacy rules for electronic reports created in accordance with those rules obliges medical doctors to keep all created electronic forms for not less than six years from the time of generation or the time when it was last in use and this is in accordance with the federal statute for restrictions for national penalties (California Medical Association 2004, 4). For controlled substance, based on Health and Safety Code 11191, every doctor of medicine who prescribes, administers or dispenses restricted substance categorized in Schedule II must make and retain records of all transaction for time period not less than three years. And this applies also to prescription books and reimbursement of Emergency Medical Service Fund. Finally, for HMOs and carrier insurance based on contract provisions, the retention period will vary (California Medical Association 2004,5). In conclusion for California State, the California Medical Association (CMA) agreed that although a retention time of not less than 10 years is possibly sufficient, it advocates that the entire medical records should be kept until further notice or for 25 years.
Alabama Statutory Medical Records Retention Periods
In Alabama we have federal law and statues guiding medical facilities in regard to how long patients’ medical report should be kept. In particular how long medical records must be retained is based on the kind of the record and specific federal or legal requirements. Under the provision of Alabama Medical Liability Act, professional responsibility is limited to four years (MAG, 2000). Nevertheless, based on the kind of medical services rendered by the general practitioner; inquiry should frequently be made with the applicable federal and/or state authorities. As far as medical records are concerned the Alabama Department of Health recommends five (5) years for adults and for children should be not less than twenty-four (24) years (MAG, 2000). Common medical office reports, Medical records of children, X-rays and Medicare records must be kept for ten (10) years after last visit. While for deceased individuals, reports must be retained for at least ten years. Finally immunization medical report must be retained indefinitely (MAG 2000). It should be noted that even though there might be regulations as to how long medical reports must retained, in general, medical data records retention period depends on type of information and varies from state to state.
CMA Legal Counsel. (2004). Retention of Medical Records. The California Medical Association’s Information-on-Demand Service.
Dixon L.A. (2007).Medical Record Retention. International Publishing Group
MAG Mutual Insurance (2000). How Long Should I Retain My Patients’ Medical Records in Alabama? Record Retention. Web.