Medical Record Retention: What You Need to Know

Last Updated: Nov 28, 2017

The Pennsylvania Medical Society (PAMED) often receives questions regarding medical record retention from member physicians.

Retention Requirements

Andrew-Harvan 

Andrew Harvan, JD

Pennsylvania physicians are required to retain medical records for adult patients for at least seven years from the last date-of-service.

This requirement is codified in nearly identical regulations enacted by the State Board of Medicine, 49 Pa. Code §16.95, and the State Board of Osteopathic Medicine, 49 Pa. Code §25.213. Healthcare providers may establish their own policies on record retention in excess of the seven-year minimum.

Record retention requirements for minor patients differs between doctors of medicine (MDs) and doctors of osteopathic medicine (DOs). The State Board of Medicine requires that MDs retain a minor patient's records for at least seven years from the last date-of-service or one year after the patient's 18th birthday, whichever is longer. A similar State Board of Osteopathic Medicine regulation requires DOs to retain a minor patient's medical records for at least seven years from the last date-of-service or two years after the patient's 18th birthday, again whichever is longer.

For purposes of medical review and auditing as well as claim payment documentation, medical records should be retained for any minimum time-period set by the payer and for as long as the payer normally can seek a refund for overpayment. Compliance with the aforementioned licensure board retention requirements is generally sufficient. Note, however, that the Centers for Medicare & Medicaid Services (CMS) requires Medicare managed care program providers to retain patient medical records for 10 years (see 42 CFR 422.504 (d)(2)(iii)).

Medical Liability Defense
Proper medical record retention can be extremely beneficial to the defense of medical liability claims. In Pennsylvania, a medical liability claim must be filed two years from the date of reasonable discovery, the statute of limitations (42 Pa. CSA §5524), or seven years from the date of the alleged negligence, the statute of repose (40 P.S. § 1303.513), whichever is shorter. A medical liability claim may be filed by or on behalf of a minor up to seven years after the incident or until the minor reaches the age of 20, whichever is later. The seven-year limit does not apply to cases of foreign objects left in a patient's body, such a claim must be filed within two years of discovery of the object.

The seven-year retention requirement applies regardless of whether the patient is deceased. A physician may need medical records to document care provided to the deceased. Medical records might also be needed by a physician to defend a medical liability action brought by the patient's estate (a survival action) or dependents (wrongful death action). Survival and wrongful death actions generally must be brought within two years of the patient's death. Additionally, medical records could also be needed for other legal proceedings such as probate and estate administration.

Where Can I Find More Information?
PAMED's Quick Consult fact sheet on "Retention & Disposal of Med Records" thoroughly discusses legal requirements regarding the content, alteration, retention, and disposal of medical records. This Quick Consult also answers several frequently asked questions on medical record retention/disposal and includes an example disposal documentation form.

For information on this topic and much more, visit PAMED’s Legal Resource Center at  www.pamedsoc.org/LegalResourceCenter. PAMED's Legal Resource Center provides quality, timely legal advocacy and resources for member physicians.

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