POLICIES > Medical Records

PURPOSE: To provide an appropriate policy and procedures for the retention of medical records under the control of the Reorganized Los Medanos Community Hospital District (the "District"). In adopting this Policy, the Board of Directors of the District (the "Board") intends to comply with all federal and State of California legal requirements and to serve the needs of its former patients as to the proper storage, maintenance, disclosure, and eventual appropriate destruction of their medical records, while at the same time meeting its obligation to provide for the judicious use of its assets.

POLICY: All medical records that are under the control of the District shall be maintained in keeping with the procedures described below. Once the retention period, as set forth in this Policy, has expired for a given record, that record shall then be destroyed in accordance with the Policy. At all times, each medical record under the control of the District shall be kept confidential at all times in accordance with the requirements of California and federal law. This Policy and its procedures shall apply to all medical records under the control of the District, whether such records are stored and managed by the District itself or by an off-site record management service approved by the Board. Consequently, this Policy and its procedures shall be incorporated into any agreement between the District and any off-site record management service regarding the storage, maintenance, disclosure, and eventual appropriate destruction of any medical record under the control of the District.

DEFINITION OF "MEDICAL RECORDS": "Medical Records" means documented information, including demographic information, regarding an identified individual's health or health care, whether documented on paper, microfiche, X-ray film or computer disk, and that consists of any of the types of information listed on Attachment A hereto. "Medical Records" does not mean documented information which does not identify, and cannot readily be linked with, the individual to whom it pertains.

PROCEDURES:

1. Retention Periods for Medical Records. All medical records of persons aged 18 years and older and of emancipated minors shall be retained for seven (7) years from date of service. All medical records of persons who were under the age of 18 years at the time service was rendered shall be retained for the greater of (a) one (1) year from the date the person reaches the age of 18 years, or (b) seven (7) years. Compliance with these requirements imposed by California law will result in compliance with current federal medical record retention provisions, which generally require a five (5) years retention period or less.
   
   
2. Transportation, Storage and Maintenance of Medical Records. Transportation, storage and maintenance of medical records shall take place in a secure environment where the medical records are protected at all times from physical damage, loss, unauthorized review and commingling.
   
   
3. Indexing of Medical Records. In order to make possible the release of medical records in accordance with federal and California law, the Board or its designee shall arrange for the medical records to be indexed and stored in a manner that allows them to be retrieved for authorized disclosures. The Board retains discretion and has wide latitude in determining the actual method of indexing and storage, in order to meet its fiscal obligations and preserve its assets.
   
   
4. Release and Disclosure of Medical Records
   
   

   a.

   Release and Disclosure. Each release and disclosure of medical records shall be in accordance with federal and California law. Unless otherwise authorized by law, disclosures of medical records shall be made only when authorized in writing by the patient or the patient's authorized representative. If the District retains a records management service to store and maintain the medical records, the District shall satisfy itself that the release and disclosure policies of that service are in accordance with federal and California law, and that the service takes appropriate steps to ensure its employees' and agents' compliance with such laws.

   b.

   Consideration of Policy Releasing Original Medical Records to Patients. Recognizing that all medical records under the control of the District are now at least five (5) years old, and acknowledging the significant costs involved with maintenance and storage of those records, the District may in its discretion consider adopting a policy authorizing the permanent release of original medical records, that are still within the retention period specified in Paragraph 1 above, to patients or their authorized representatives. Prior to the adoption of such a policy, the Board shall consider the effect of such a policy on (1) the District's ability to defend itself from lawsuits related to the patient's treatment; (2) the District's ability to thereafter provide the medical records in response to any government investigation and concomitantly, the feasibility of seeking the approval of the California Department of Health Services for such a policy; and (3) the patient's individual health care providers' ability to defend themselves from lawsuits related to the patient's treatment, and the relative benefits and costs related to any voluntary decision of the Board to notify such providers of the transfer of original medical records to a patient or authorized patient representative.

   
   
   
5. Destruction of Medical Records. Those medical records that are older than the retention period specific in Paragraph 1 above shall promptly be destroyed, except that records shall not be destroyed that are involved in any open investigation, audit, or litigation. In addition, any record identified for destruction may instead be permanently released to the patient or the patient's authorized representative. The District is not required, but may in its discretion decide, to notify patients of the intended destruction of their medical records.
   
   

   a.

   Methods and Process of Destruction. The destruction of medical records by the District or its agent shall be carried out in such a way as to protect the confidentiality of the medical records. At a minimum, the transport of the records to the destruction site and the actual destruction shall be carried out by persons who are contractually obligated to:(1) maintain confidentiality, and refrain from reviewing the contents of the records or disclosing them to any other person; (1)    maintain confidentiality, and refrain from reviewing the contents of the records or disclosing them to any other person; (2)    ensure that the destruction process results in no possibility of reconstruction of information. Appropriate methods for destroying paper records include burning, shredding, pulping, and pulverizing. Methods for destroying microfilm or microfiche include recycling and pulverizing. If computerized medical records are to be destroyed, methods of destruction shall be used that destroy the data permanently and irreversibility, such as overwriting or reformatting computer disks and overwriting any back-up tapes. The appropriate method of destruction for laser disks used in write-once-read-many (WORM) document imaging applications is pulverization; (3)    indemnify the District against loss due to unauthorized disclosure; (4)    accomplish destruction of the records within a stated period of time between the eligibility of medical records for destruction and the actual date of destruction; and (5)    provide proof of destruction, including the date and method of destruction and the signatures of the individuals supervising and witnessing the destruction.

   b.

   Documentation of Destruction. Unless otherwise specified by the Board, documentation of the destruction of medical records should be maintained by the District for a minimum of two (2) years after the destruction. Such documentation shall include the proof of destruction provided by the persons supervising the destruction; if feasible, an index of the names of patients whose records were destroyed or at a minimum, a notation of the dates of service destroyed on a given day; and a statement that the records were destroyed in the normal course of business.

The following documents constitute portions of a medical record, as defined by the State of California:

Admission records
Autopsy reports and consents
Consent forms
Consultation reports
Labor and delivery records
Laboratory notes
Nurses' notes
Pathologists' reports
Patient histories
Patient identification information
Physical examinations
Physicians' orders
Progress notes
Reports of all other tests, such as EKG, EEG, etc.
Summary or final diagnoses
Surgical records, including anesthetic records, findings, operative procedures, postoperative
diagnoses, preoperative diagnoses and tissue diagnoses
Temperature charts
Vital sign sheets
X-ray reports