Retention of Records
There are few statutory requirements on how long a medical office must retain private office records. From a risk management point of view, it is desirable for all records to be retained indefinitely in the office. Unfortunately, this may be economically unfeasible and interfere with access to active records. All medical offices should have a formal records retention policy that balances convenient and economic storage with easy access to active records.
Records for any patient seen in the last two years must be considered active unless the patient has died. If the patient has not been seen for two years and does not have a continuing medical condition, the medical care practitioner may consider putting the patient’s records into less accessible storage while retaining the cover sheet of the chart in case the patient is seen again. The cover sheet will facilitate urgent care in either the office or the emergency room before the full record can be retrieved.
The medical care practitioner must maintain a separate tracking system for all patients with implants of any kind. Although this has always been done for heart valves and pacemakers, it is important for other implants that either need replacing or are subject to FDA (Food and Drug Administration) recalls or reviews. This includes intrauterine devices and implantable contraceptives, including Depo- Provera. The tracking system should identify each patient with an implant, the type of implant, the last patient visit, and any necessary review dates. For implantable contraceptives, such as Norplant, the patient should be seen each year and should be notified in the fourth year that the contraceptive effect is wearing off. For Depo-Provera, the patient must be followed up every three months, or whatever is the effective length of the preparation that is used.
The physician should contact patients with chronic medical problems who have not been seen recently. If the patient is being treated by a new physician, that physician’s name should be noted in the chart. If the patient cannot be found and is not in need of specific follow-up care, the physician should send a postcard to the patient’s last known address. If the card is returned as undeliverable, it should be put in the chart to document that the physician tried to keep track of the patient. Once the patient has been accounted for, the chart may be moved to storage. If there are patients in need of follow-up care, they should be managed as discussed in the section on the physician- patient relationship.
From a strictly legal point of view, the statute of limitations for medical malpractice in the state where the physician practices is the absolute minimum period that records should be maintained. Depending on the local state laws, adults have from one to four years after the occurrence of an injury to file a claim for medical malpractice. For children, this period is usually extended until the patient reaches age 20 to 24.
The problem with the statute of limitation is that states tend to measure the period differently. The statute of limitations may begin to run: (1) on the date when the malpractice occurred, whether the patient knew about the malpractice or not; (2) on the date when the physician last treated the patient for the condition at issue; or (3) on the date the patient knew, or should have known, that he or she was a victim of malpractice. In states in which the running of the statute of limitations starts from the discovery of the malpractice, it is conceivable that a malpractice suit could be filed 10, 15, 20, or more years after the patient was treated.