Medical Records and the Law

Record Retention Requirements 47retention period for medical records information, as determined by lawand regulation and the uses of the information for patient care for legal,research, and educational purposes. The Community Health AccreditationProgram, however, states that the records of occupationally exposedpatients must be retained for 30 years. 45Developing a Record Retention PolicyIn the final analysis, no blanket record retention rule for all types ofhealthcare providers can be devised.The length of time medical recordsshould be retained after they no longer are needed for medical and administrativepurposes should be determined by the physician or the facility’smanagement with the advice of qualified legal counsel, takinginto account all relevant factors, including the feasibility and cost ofconverting paper records to a storage medium, the availability and costof storage space, the cost of maintaining retrieval devices, and the possiblefuture need for such records, as well as the legal considerations relatedto lawsuits. In most professional negligence actions against ahealthcare facility or provider, the defendant must show that the careprovided was consistent with accepted medical practice at the time andwas reasonable under the circumstances. Medical records are essentialto the defense of such actions. Although, in the absence of some specialrelationship or contractual duty between the parties, courts generallyreject the existence of a responsibility by one party to preserveevidence or records for another party’s potential suit, 46 several courtshave recognized a hospital’s duty to maintain patient records as a matterof statute or regulation. 47Specifically, in cases where the plaintiff had insufficient evidence topursue a professional liability action against a hospital because the hospitalwas unable to produce the patient’s record, courts have found thefacility liable for this independent act of negligence or have ruled thatthe plaintiff states a cause of action in negligence.45For a summary of accrediting-agency rules concerning retention of health information,see American Health Information Management Association, Practice Brief: Retention ofHealth Information (Updated) ( June 2002), 2, available at http://library.ahima.org/xpedio/groups/public/documents/ahima/pub_bok1_012545.html.46See Panich v. Iron Wood Products Corporation, 445 N.W. 2d 795 (Mich. Ct. App. 1989);Koplin v. Rosel Well Perforators, Inc., 734 P. 2d 1177 (D. Kan. 1987).47See, e.g.,Fox v. Cohen, 406 N.E. 2d 178 (Ill. Ct. App. 1980).