Retention of Medical Records Law

1. 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

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 • 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.

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 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.

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.

8. 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? (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. 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.)

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

11. References: • http://www.sos.ga.gov/plb/chiro/TITLE%2031-%20Patient%20Record%20Laws.pdf