SHC Policy-Legal Medical Records and Radiology Film Retention ...

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
I. Purpose
The purpose of this policy is to clearly define the legal medical record for Stanford Hospital and
Clinics (SHC), including which information must be sent to the Health Information Management
(HIMS) Department for legal archival.
II. Definitions
A. Active Patient: Patient whose last health care activity is within the last ten (10) years.
B. Addendum: HIMS recognizes two types of addendums:
Last Approval Date
SHC-August 2005
Page 1 of 13
1. Clinical Addendum: An addition or change to a report after it has been finalized.
This note is added to the final report.
2. Individual Addendum to the Record: A written statement by the individual that is
added to the record.
C. Archival Medical Record: This is the record maintained to satisfy the long-term retention
requirements of the medical record. Generally, the archival medical record is the same as
the legal medical record.
D. Correct (Amend) the Record: A clinician amendment to the record that addresses
deficiencies of accuracy or completeness.
E. Designated record set means the legal medical record, billing records and any other item,
collection or grouping of information that includes protected health information (PHI), and is
maintained, collected, used, or disseminated by or for a covered entity and used to make
decisions about individuals.

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
Last Approval Date
SHC-August 2005
Page 2 of 13
F. Final Authenticated Report: The medical record report which has been verified and
authenticated, often by signing, as being correct.
G. Interfaced Documents: Electronic transfer of clinical reports from ancillary systems to the
document imaging system through an FTP or an HL7 interface.
H. Legal Medical Record: The official medical record compiling all notes and authenticated
documents concerning a patient’s care. This is the record provided for follow-up care and in
response to billing, audits, quality assurance, legal requests or research requests when
appropriate authorization is provided.
I. Paper Chart: Refers to the paper based medical record, containing all original clinical
information for a patient generated prior to January 29, 1997.
J. Radiology Film Records: The Radiology exam records refer to exams obtained for diagnostic
purposes. In their original form they can be archived on film, disc or electronic archive.
K. Scanned Records: Paper documents captured as images and stored in an electronic
computerized format called TIFF. All medical records generated on and after January 29,
1997 are scanned and stored as TIFF images.
L. Shadow Charts: Copies of medical record documentation stored locally within the clinical
areas. Originals are stored by HIMS.
M. Source Data: All original information or data or certified copies of such original information
contained in source documents.

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
N. Source Document: Documents in the medical record, which are either the original document
or copies or transcriptions certified after verification as being an exact replication of the
original document. When original observations are directly entered into a computer system,
the electronic record is the source document.
O. TIFF (Tagged Image File Format): An industry standard file format for bitmapped images
often used to exchange such files between dissimilar computers and by scanners when
converting pictures to computer form. The name comes from the specification that describes
how to store information in blocks called tags. The format accurately depicts the image of
scanned paper and is designed to store a complete image of an original paper document.
III. Policy Statement
Health Information Management Systems (HIMS) maintains the legal and archival medical records
for Stanford Hospital and Clinics (SHC). The legal medical record contains all final, authenticated
reports and is used for patient care, legal, research, audit, and billing purposes. It is the
responsibility of each clinical unit to ensure that all clinical documentation is received by or interfaced
to HIMS within 24 hours after the documentation is generated.
The SHC legal record is archived differently depending on the period of patient care:
A.Patient documentation generated on and after January 29, 1997
The legal archival record is the electronic medical record, which is scanned or interfaced,
and is stored as TIFF image or text.
B.Patient documentation generated prior to January 29, 1997
Last Approval Date
SHC-August 2005
Page 3 of 13
The legal, archival record is the paper chart stored in an off-site storage facility.

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
IV. Principles
It is the policy of SHC that patients’ legal medical records and radiology film records be
preserved safely. Adult patient and emancipated minor medical records shall be preserved
for a minimum of ten (10) years from the last date of patient care activity. The medical
records and radiology film records of unemancipated minors shall be retained for at least
one year after such minor has reached the age of eighteen (18), but in no case for less
than ten (10) years following discharge.
A. Medical records shall be maintained to document any treatment decisions about individuals.
B. Medical records shall be made available for follow-up care and in response to billing, audits,
quality assurance, legal requests, or research requests when appropriate authorization is
provided.
C. Appropriate safeguards shall be implemented to protect the security and confidentiality of all
medical records.
D. Medical records and radiology films must be retained in accordance with state guidelines and
may only be destroyed with the concurrence of the Medical Board and hospital
administration.
E. Procedures shall be implemented to insure the integrity of the medical records
F. Electronic medical records shall be backed-up using existing available technology.
V. Procedures
Last Approval Date
SHC-August 2005
Page 4 of 13
A. Medical records shall be maintained to document any treatment decisions about
individuals.

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
Last Approval Date
SHC-August 2005
Page 5 of 13
1. All archived paper records prior to January 29, 1997 are kept in an off-site storage
facility and are retrieved when needed for patient care, legal requests, audit, billing,
research requests when appropriate authorization is provided, and other purposes.
The off-site storage facilities meet all state and federal requirements for
confidentiality, security and integrity of medical record storage. Appropriate
applications to the state will be made to open a new storage facility. Access
policies and procedures are addressed in the policy titled: “HIPAA Internal Access
to Protected Health Information Policy”.
2. There are two ways medical records are entered into the electronic record:
a. Scanning: Documents are scanned and are stored electronically as
magnetic or optical TIFF images. Scanned electronic images are
unalterable, verified to be an exact replication of the original document
and are the source document. After scanning, the original paper records
are stored off-site temporarily until quality checks are done, then they are
destroyed.
b. Direct Entry: Electronic reports generated by ancillary system are
interfaced directly into the document imaging system and are indexed as
text documents. These documents are also unalterable, verified to be an
exact replication of the original document and are the source document.
3. SHC maintains a centralized medical record managed by the HIMS Department.
Some Stanford Clinics maintain shadow file systems. These files are only
authorized to hold duplicate copies of notes and reports. The shadow files should
not contain original or top copy documents.
4. Due to geographic locations, there are sites whose medical records are maintained
locally such as Vaden Student Health Center. The SHC HIMS Department provides
medical record oversight over these clinics.

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
B. Medical records shall be made available for follow-up care and in response to billing, audits,
quality assurance, legal requests, or research requests when appropriate authorization is
provided.
1. Scanned records and interfaced reports can be accessed by authorized staff using
MedRec (web-based viewer) through the hospital Intranet. Upon request and
validation of need to know, the HIMS Department can print appropriate sections of
the medical records.
2. Archived paper records prior to January 29, 1997 can be retrieved from off-site
storage when requested.
C. Appropriate safeguards shall be implemented to protect the security and confidentiality of all
medical records.
1. SHC has procedures to protect the confidentiality and security of patient
information. These are set forth in a series of policies, including the following:
• Confidentiality Principles Regarding Patient Information
• User ID and Password
• HIPAA Internal Access to Protected Health Information Policy
• Workstation and Application Timeout
• Off Campus Access to Electronically Stored Patient Data
• Audit of Access to Electronic Patient Information
Last Approval Date
SHC-August 2005
Page 6 of 13
2. SHC has implemented security measures and software safeguards to prevent
unauthorized access to the paper records and computerized systems.

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
Last Approval Date
SHC-August 2005
Page 7 of 13
a. Paper medical record files shall be stored in an area that limits access to
authorized personnel only. Records in use shall be located in an area
secure from public access.
b. User IDs and passwords protect information systems that contain
electronic medical record information. Managers determine which staff
needs access and approve requests for those employees (based on
minimum necessary requirements for their role). The IT Access Control
Unit controls the issuing and termination of UserID’s and passwords.
Passwords expire on a scheduled basis. Computer screens are
designed to time-out when not active for a specified time. Sharing
passwords is a cause for disciplinary action, including termination of
employment.
D. Medical records and radiology films must be retained in accordance with state guidelines
and may only be destroyed with the concurrence of the Medical Board and hospital
administration.
1. It is the policy of SHC that a patient’s legal medical records are preserved safely.
a. Adult patient and emancipated minor records shall be preserved for a
minimum of ten (10) years from the last date of patient care activity.
b. The records of unemancipated minors shall be retained for at least one
year after such minor has reached the age of eighteen (18), but in no
case less than ten (10) years following discharge.
2. The California Healthcare Association’s “Record Retention Guide” serves as the
resource on retention of records.

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
3. Retention of original records that have been scanned.
a. These are the original copies of the scanned records. The TIFF images,
which are exact representation of these paper documents, become the
legal record.
b. After scanning, the original paper records are stored temporarily offsite
until quality checks are done, then they qualify for destruction.
4. Retention of Shadow Medical Records
The shadow records are not the legal records and are used by clinic physicians and
other outpatient areas for their convenience. It is the responsibility of each clinical
area to ensure that all source documents are delivered to the HIMS department for
archiving.
5. Destruction of Medical Records and Radiology Film
Last Approval Date
SHC-August 2005
Page 8 of 13
a. The legal medical records and radiology film qualify for destruction when
patients are inactive for more than ten (10) years. Records qualify for
destruction when they exceed the criteria as defined in paragraph D 1
above.
b. The Director of HIMS (Medical Records) may authorize destruction of the
legal medical after consultation and approval of Hospital Administration
and the Medical Board. The Director of Radiology may authorize the
retention or destruction of the original radiology films or the electronically
archived images after consultation and approval of Hospital
Administration and Medical Board.

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
c. Since the HIMS Department maintains the legal record, the shadow
records may be destroyed at the convenience of the clinic or when
deemed necessary due to space constraints and patient inactivity. The
responsible Vice President may authorize destruction of this patient
information after ensuring that all original documentation has been
delivered to HIMS.
d. The hospital has several options for destroying inactive, paper records.
The procedure is the same for destroying legal medical records, shadow
charts or other ancillary information:
1. Contract with an outside vendor to shred or burn paper records.
If this option is used, the vendor is required to provide a
Certificate of Destruction when the work is completed. The
management group authorizing the destruction should keep this
record.
2. Destroy paper records in-house
Last Approval Date
SHC-August 2005
Page 9 of 13
e. Destruction of inactive imaging records occurs when the criteria for film
disposal have been met. The Radiology Imaging Manager will contact a
vendor who is licensed to dispose of hazardous materials (re: films
containing silver) according to State and Federal Regulations.
E. Procedures shall be implemented to insure the integrity of the medical records. (See the
SHC policy “Document Scanning Verification Process”)
1. The paper medical records stored off-site are tracked using an electronic chart
locator application. Records stored within the off-site storage facility are also
tracked using their own chart locator system.

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
2. It is the responsibility of each clinical unit to ensure that all clinical documentation is
delivered or interfaced to HIMS within 24 hours after the documentation is
generated. HIMS tracks receipt of Inpatient, Emergency, and Outpatient Surgery
records. Discharge records not received or partially missing records are tracked in
a database and are followed-up on a daily basis by the HIMS Discharge Control
Team.
3. The document imaging process is subject to specific verification and quality controls
requirements (see the SHC “Document Scanning Verification Process” policy).
F. Electronic medical records shall be backed-up using existing available technology.
The SHC electronic medical record (EMR) is maintained on a RAID 5 Storage Area Network
(SAN) and is backed up daily.
VI. Related Documents or Policies
A. Medical Record Documentation Policy
B. Document Scanning Verification Process
C. HIPAA Internal Access to Protected Health Information Policy
D. HIPAA Correction (Amendment) of Protected Health Information and Addendum Policy
E. HIPAA Designated Record Set Policy
F. HIPAA “Minimum Necessary” Use and Disclosure of, and Requests for, Protected Health
Information
G. Audit of Access to Electronic Patient Information
H. Confidentiality Principles Regarding Patient Information
I. User ID and Password (sunsetted 2004)
J. Workstation and Application Timeout (sunsetted 2004)
Last Approval Date
SHC-August 2005
Page 10 of 13

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
VII. Document Information
A. Legal Authority/References
1. Title 22: California Code of Regulations
2. Joint Commission on Accreditation of Hospitals (JCAHO): IM Standard
3. Health Care Financing Administration
4. Code of Federal Register: 21 CFR Part 11 and FDA Guidelines on Electronic
Records
5. Federal Register, Vol. 65, No. 250, December 28, 2000, pages
82798 to 82829
6. Federal Register, Vol. 67, No. 157, August 14, 2002, pages 53181 to 53273
7. California Healthcare Association: Record Retention Guide
B. Author/Original Date
February 2001, D. Myjer, PhD, Director of HIMS, and R. Madamba, RHIA, Manager of
Record Archiving
C. Gatekeeper of Original Document
Administrative Manual Coordinators and Editors
D. Distribution and Training Requirements
Last Approval Date
SHC-August 2005
Page 11 of 13
1. This policy resides in the Administrative Manual of Stanford Hospital and Clinics.
2. New documents or any revised documents will be distributed to Administrative

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
Manual holders. The department/unit/clinic manager will be responsible for
communicating this information to the applicable staff.
E. Review and Renewal Requirements
This policy will be reviewed and/or revised every three years or as required by change of law
or practice.
F. Review and Revision History
September 2003, revised D. Myjer, PhD, Director of HIMS, and R. Madamba, RHIA, Manager
of Record Archiving
G. Approvals
February 2001, HIMS Management
February 2001, SHC HIM Committee
June 2001, Legal Review by Ropes and Gray
August 2001, SHC Medical Board
August 2001, SHC Hospital Board
April 2003, LPCH Medical Board
April 2003, LPCH Board of Directors
September 2003, HIMS Management
Date Pending, SHC HIM Committee
March 2004, Quality Improvement Patient Safety Committee
Date Pending, Legal Review by Ropes and Gray
August 2005, SHC Medical Board
Last Approval Date
SHC-August 2005
Page 12 of 13

This policy applies to:
Stanford Hospital and Clinics
Lucile Packard Children's Hospital
Stanford University
Name of the Policy:
Legal Medical Record and Radiology Film Retention and
Destruction
Departments Affected:
All Departments
August 2005, SHC Hospital Board
This document is intended for use by staff of Stanford Hospital & Clinics and/or Lucile Packard Children's Hospital.
No representations or warranties are made for outside use.
Not for outside reproduction or publication without permission.
Last Approval Date
SHC-August 2005
Page 13 of 13