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Home >  Frequently Asked Questions (FAQ's)  >  Medical Records  


Frequently Asked Questions (FAQ's)

- Medical Records 


{short description of image}What is the law on retention of medical records in Georgia? Florida? North Carolina?

{short description of image}Does the AMA have a policy on medical records?

{short description of image}Can a Physician charge patients for medical record copies in Georgia?

{short description of image}Where can I find information about Medicare's signature requirements for medical records and whether or not the use of a signature stamp is acceptable?

{short description of image}If patients request copies of their medical records as permitted by the Privacy Rule, are they required to pay for the copies?

{short description of image}Is a copy, facsimile, or electronically transmitted version of a signed Authorization valid under the Privacy Rule?


{short description of image}What is the law on retention of medical records in Georgia? Florida? North Carolina?

Just how long medical records should be kept depends upon the type of record, its potential use and specific legal requirements.

Georgia - By statute, the general rule is that medical records in the medical office (including any notes, lab reports and biopsy slides) must be maintained for at least 10 years from the date the item was created, usually the date of the last visit or treatment. Certain limited exceptions apply to the 10-year rule. By contrast, hospital records should be retained for at least 6 years after the patient's most recent discharge. Minor patients' records are handled differently; they should be maintained until the patient reaches their 27th birthday.

Finally, records should be kept indefinitely in riskier situations, including where there is an undesirable outcome, when a patient is unhappy with a result or any time a patient threatens or files a lawsuit.

North Carolina - Just how long medical records should be kept depends upon the type of record, its potential use and specific legal requirements.

By statute, the North Carolina Department of Health and Human Resources is charged with creating policy regarding "health care facilities", including hospitals. According to the DHR's Rules, medical records of a facility must be maintained for at least 11 years after an adult patient's discharge. Minor patients' facility records are handled differently; they should be kept until the patient reaches their 30th birthday.

North Carolina does not have a medical office record retention statute. We therefore recommend that these records be maintained for as long as "facility" records are.

Finally, records should be kept indefinitely in riskier situations, including where there is an undesirable outcome, where the patient was or might have been legally incompetent at the time of treatment or becomes legally competent thereafter (including cases involving brain damage, Alzheimer's Disease and other mental and emotional disabilities), when a patient is unhappy with a result or any time a patient threatens or files a lawsuit.

In Florida, the length of time a physician should retain his or her patients' medical records varies according to the type of medical records, reason for their disposition and their potential use. In general, we recommend that medical records be retained for at least 12 years after a patient's last visit or treatment.

By statute, the general rule is that medical records should be kept for a period of 5 years after the last patient contact. However, the state statute specifically requires physicians to retain medical records as long as needed to protect and serve patients as well as to protect against malpractice actions filed after the termination of the physician-patient relationship. Community standards, individual practice settings and specific patient needs may require longer record retention periods.

Medical records should be retained for at least 2 years after a physician's death, termination of practice, or relocation.

Florida's Statute of Repose, housed within the Statute of Limitations, provides that certain medical malpractice lawsuits can be filed up to 7 years from the date of the alleged negligent conduct. Therefore, the mandatory 5 year record retention period could end before a medical malpractice lawsuit is even filed. As such, we recommend that medical records be kept for 12 years after a patient's last visit or treatment date.

{short description of image}Does the AMA have a policy on medical records?

Yes, physicians have an obligation to retain patient records which may reasonably be of value to a patient. The following guidelines are offered to assist physicians in meeting their ethical and legal obligations:

(1) Medical considerations are 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 whether a physician would 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.

(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.

{short description of image}Can a Physician charge patients for medical record copies in Georgia?

The Georgia Office of Planning and Budget (OPB) pursuant to O.C.G.A. § 31-33-3, calculates an annual inflation adjustment for the costs related to medical record retrieval, certification and copying.

Effective July 1, 2005

Search, Retrieval, and Other Direct Administrative Costs Up to $24.86
Certification Fee Up to per record $9.32
Copying Costs for Records in Paper Form

Per page for pages 1-20

$0.93
 

Per page for pages 21 - 100

$0.80
 

Per page for pages over 100

$0.63

Notes

The HIPAA Privacy Rule prohibits the charge for Search, Retrieval and Other Direct Administrative Costs from being assessed against the patient or the patient's personal representative who requests medical records. The HIPAA prohibition does not apply to requests by other persons.

The HIPAA Privacy Rule prohibits providers from charging to convert medical records into a form or format requested by the individual, if it is readily producible in such form or format, or into a readable hard copy form or other agreed upon form or format. However, if the individual wants a copy of a non-paper medical record, then a Georgia hospital may charge a reasonable, cost-based fee for copying the record, including the cost of supplies and copying labor.

Physicians and hospitals may charge the actual cost (i.e., postage) of mailing the requested records.

Physicians may charge for summaries of health records.

A physician or hospital may not assess copying costs in the case of a person seeking records for the purpose of applying for disability benefits coverage.

{short description of image}Where can I find information about Medicare's signature requirements for medical records and whether or not the use of a signature stamp is acceptable?

The Centers for Medicare and Medicaid Services (CMS) has revised the Medicare Program Integrity Manual. The complete Medicare Program Integrity Manual can be viewed online at http://www.cms.hhs.gov/manuals/108_pim/pim83toc.asp .Medicare requires a legible identity for services provided or ordered. The method used (e.g. hand written, electronic, or signature stamp) to sign an order or other medical record documentation for medical review purposes in determining coverage is not a relevant factor. Rather, an indication of a signature in some form needs to be present. Medicare will not deny a claim on the sole basis of type of signature submitted. Providers using alternative signature methods (e.g. a signature stamp) should recognize that there is a potential for misuse or abuse with a signature stamp or other alternate signature methods. For example, a rubber stamped signature is much less secure than other modes of signature identification. The individual whose name is on the alternate signature method bears the responsibility for the authenticity of the information being attested to. Physicians should check with their attorneys and malpractice insurers in regard to the use of alternative signature methods. All State licensure and State practice regulations continue to apply. Where State law is more restrictive than Medicare, the contractor needs to apply the State law standard. The signature requirements described here do not assure compliance with Medicare conditions of participation. Note that this instruction does not supersede the prohibition for Certificates of Medical Necessity (CMN). CMNs are a term of art specifically describing particular Durable Medical Equipment forms. As stated on CMN forms, "Signature and date stamps are not acceptable" for use on CMNs. No other forms or documents are subject to this exclusion.

{short description of image}If patients request copies of their medical records as permitted by the Privacy Rule, are they required to pay for the copies?

The Privacy Rule permits the covered entity to impose reasonable, cost-based fees. The fee may include only the cost of copying (including supplies and labor) and postage, if the patient requests that the copy be mailed. If the patient has agreed to receive a summary or explanation of his or her protected health information, the covered entity may also charge a fee for preparation of the summary or explanation. The fee may not include costs associated with searching for and retrieving the requested information.

{short description of image}Is a copy, facsimile, or electronically transmitted version of a signed Authorization valid under the Privacy Rule?

Yes. Under the Privacy Rule, a covered entity may use or disclose protected health information pursuant to a copy of a valid and signed Authorization, including a copy that is received by facsimile or electronically transmitted.


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