Executive Offices and General Records

Administrative Subject Files
Includes: Correspondence, reports, and statistical information concerning the administrative functions of hospitals.

Administrative Subject Files - Executive

Administrative Subject Files - General/Departmental

Annual Reports

Annual Reports (Original)

Annual Report (Copies)

Articles/Certificates of Incorporation

Budget Records

Budget Reports - Annual (Original)

Budget Reports - Annual (Copies)

Budget Workpapers

By-Laws of the Hospital Board

Certificate of Need Application

Correspondence

Correspondence - External

Correspondence - Internal

Correspondence - Policy/Directives

Deeds

Disaster/Evaluation Plans

Employee Opinion Surveys/Suggestions

Financial Transaction

Financial Transaction Status Reports (Original)

Financial Transaction Status Report (Copies)

Licensure Files
Includes: license, renewals, correspondence, and surveys by the Department of Health. License is renewed annually.

Minutes
Includes: staff meetings, hospital board, and committees.

Minutes (Original)

Minutes (Copies)

Monthly Reports

Monthly Reports (Original)

Monthly Reports (Copies)

Organization Charts

Organization Charts (Original)

Organization Charts (Copies)

Policy and Procedures Manuals

Policy and Procedures Manuals (Original)

Policy and Procedures Manuals (Copies)

Quality Assurance Reports - Departmental (Copies)

Research Reports and Studies

Statistical Reports

Statistical Reports - Annual

Statistical Reports - Quarterly and Monthly

Statistical Reports - Weekly

Statistical Reports - Daily

Statistical Reports (Copies)

Human Resources/Personnel

Personnel Files
May include but are not limited to: application, resume, benefits information and contract, annual time card, pension calculations, statements of benefits coverage, health background, evaluations, blood type, correspondence, and Notice of Proceeding Involving Practitioner.

Personnel Record Card
Includes: name, dates of service, and social security number, etc.

Residency Personnel File

Student Education File
Includes: grades, evaluation, and work schedule, etc.

Time Cards/Sheets

Time Cards/Sheets (Original)

Time Cards/Sheets (Copies)

Unsuccessful Job and Residency Applications

Student Application Log/Intern Register

Resident’s Surgical Procedures Performed
Consist of a listing containing names of residents and procedure performed during four (4) year residency.

Employee Medical Records   

Planning

Planning Subject File
Used for long range planning and development of the hospital.

Planning Subject File - Plans

Planning Subject Files - Workpapers

Donor Files
Includes: name, address, and amount of donation.

Ledger - Daily Cash Book

0152-0000

News Clippings and Ads

3 years

0153-0000

Prospect Cards
Consist of index cards of prospective donors for fund raising    

3 years after update

Marketing - Public Relations

0200-0000

Photographs

Permanent

0201-0000

Press Releases

Permanent

0202-0000

Public Service Announcement

Permanent

0203-0001

Publications (Original)

Permanent

0203-0002

Publications (Copies)

Periodic review

Marketing - Volunteer Services

0250-0000

Sign-In Sheets

3 years

0251-0000

Time Cards - Hours Worked

3 years

0252-0000

Training Materials and Handouts

3 years after update

0253-0000

Volunteer Application Files - Adult and Junior

6 years after termination of employment

Include: application, reference letters, interview sheet, checksheet, and Utilization Form which indicates position, needs, job description and placement.   

0300-0000

Educational Programs

3 years after update

0301-0000

Education Training Files
Includes: R.N., L.P.N., Unit Secretaries and Nursing Technicians. Contains test booklets and test results.    

6 years after termination of employment

Education - In Service Education

0350-000

Cardio - Pulmonary Resuscitation (CPR) Training
Includes: test results, test booklets, test result strips, and skill sheet

3 years

0351-0000

CPR Certificate Roster

3 years

0352-0000

First Aid Roster

3 years  

0353-0000

Screening Registration Form
Includes: diabetes, hypertension, glaucoma, breast, colon-rectal and cholesterol screens, and information release form.  

3 years

Nursing - Administration

0400-0000

Nursing Licenses (Copies)

6 years after termination of employment

0401-0000

Nursing Schedules

6 years

0402-0000

Twenty-Four Hour Report  

3 years

Nursing - Ambulatory Care

0450-0000

Ambulance Log Slips

6 years

0451-0000

Ambulance Records Book/Register  

10 years after final entry

Nursing - Central Supply

0500-0000

Equipment Use Record
Records date used and by whom

3 years

0501-0000

Steam Sterilization Control Record
Includes: Bouse-Dick chart test, graph, load card, gas sterilizer load card, and biological monitoring form, etc.

3 years

0502-0000

Syringe and Needle Control Record

3 years

0503-0000

Syringe and Needle Inventory Sheet

1 year

0504-0000

Syringe and Needle Worksheet

3 years

0505-0000

Washer/Sterilizer Cleaning Log Sheet

3 years

Nursing - Surgery/Operating Room

0550-0000

Autoclave Graphs - Sterilization

3 years

0551-0000

Birth Logs

Permanent

0552-0000

Hospital Infection Statistical Report

3 years

0553-0000

Infection Report Form

3 years

0554-0000

Operating Room Cancellation List

1 year

0555-0000

Operating Room Charge Sheet (Copy)
Original maintained by Finance

3 years

0556-0000

Operating Room Reservation Sheet

1 year

0557-0000

Operating Room Log

10 years

0558-0000

Patient Record (Copy)

2 years

Used to monitor patient’s progress after surgery. Original located in patient’s medical record.

0559-0000

Temperature and Humidity Log

3 years

   Back to Table of Contents

0600-0000

Arthroscopy Video Tapes

5 years

0601-0000

Crash Cart Checklist
List: Contents of each cart, date and nurses’ signatures.

5 years

0602-0000

Defibrillator Checklist

3 years

0603-0000

Pre-Operative and Post-Operative Checklists

3 years

0604-0000

Recovery Room Log
Includes minor surgery and same-day surgery

10 years

0605-0000

Weekly Duty List/Schedule

6 years

Nursing - Emergency Room

0650-0000

Emergency Department Log and/or Card Files

3 years

0651-0000

Emergency Room Daily Statistics

1 year

0652-0000

Mobile Intensive Care Unit Audit Tapes

3 years

   Back to Table of Contents

Professional Services - Laboratory

0700-0000

Blood Bank -(Immunohematology) Proficiency and Clinical Laboratory Test Reports (Copies)
Includes records of transfusions and crossmatches. Originals maintained in patient medical report. May also include Test Requisitions.

5 years

0701-0000

Appointment Log

3 years after final entry

0702-0000

Blood Bank Register

Permanent

0703-0000

Cytology Reports - Positive and Negative

20 years

0704-0000

Graphs

2 years

0705-0000

Instruments Maintenance Reports/Medicine Calibrations

2 years

0706-0000

Laboratory Test Log Books

2 years after final entry

0707-0000

Machine Log

Life of the instrument plus 3 years

0708-0000

Quality Control Reports - Blood Bank

5 years

0709-0000

Workbooks - Urine Screening Tests

2 years

0710-0000

Specimen Records
Includes identifying information, test results, and reports. Also used for Quality Control and Proficiency Test Results.

0710-0001

Specimen Records - Immunohematology (Blood Bank)
Test Reports, Test Results, and Identifying Information

5 years

0710-002

Specimen Records - Pathology Test Reports

20 years

0710-0003

Specimen Records - General Test Reports

2 years

0711-0000

Bone Marrow Reports

20 years

0712-0000

Blood Bank Donor and Recipient Cards

5 years

0713-0000

Blood Bank Employee Signatures, Initials and Identification Codes

5 years after termination of employment

0714-0000

Accession Log

2 years

   Back to Table of Contents

Professional Services - Pathology

0750-0000

Autopsy Reports (Copy)
Original maintained in Medical Records

20 years

0751-0000

Death Register Books

Permanent

0752-0000

Death Slips and Mortician’s Release

6 years

0753-0000

Pathology Report on Lab Results (Copy)
Original located in patient’s medical record

2 years  

Professional Services - Psychiatry

0800-0000

Social Services Patient Files - Notes and Workpapers

10 years from most recent discharge or age 23, whichever is longer

0801-0000

Social Services Patient Files - Summary Sheet

20 years

0802-0000

Social Services Patient Files - Index

20 years

Professional Services - Pediatrics

0850-0000

Nursery Daily Statistics

3 years

0851-0000

Pneumogram

0851-0001

Pneumogram - Interpretation Report

23 years

0851-0002

Pneumogram - Graph   

5 years

Professional Services - Cardiopulmonary

0950-0000

Electrocardiograms/Echocardiograms

0950-0001

Electrocardiograms/Echocardiograms - Diagnostic and Interpretation Report

10 years or age 23, whichever is later

0950-0001

Electrocardiograms/Echocardiograms - Graphs

5 years

0951-0000

Holter Monitor

0951-0001

Holter Monitor - Diagnostic and Interpretation Report

10 years or age 23, whichever is later

0951-0001

Holter Monitor - Graph

5 years

0952-0000

Machine Calibration Log

Life of the instrument plus 2 years

0953-0000

Outpatient Medical Charts

10 years after most recent discharge or age 23, whichever is later

0954-0000

Work Schedules    

3 years

Professional Services - Neuro Sciences

1000-0000

Electroencephalograms

1000-0001

Electroencephalogram - Explanation and Interpretation Report

10 years or age 23, whichever is later

1000-0002

Electroencephalograms - Graphs

5 years

1001-0000

Machine Calibration Log

Life of the instrument plus 2 years

1002-0000

Work Schedules  

6 years

Professional Services - Dietary

1050-0000

Cashier Tapes - Cafeteria

3 years

1051-0000

Diet Information Sheet - Daily

1 year

1052-0000

Dietary Instructions Log

3 years after final entry

1053-0000

Food Tally - Daily Production Sheet

3 years

1054-0000

Patient Meal Count - Daily

3 years

Professional Services - Diagnostic and Therapeutic Services

1100-0000

Outpatient Files

10 years after most recent discharge or age 23, whichever is later

1101-0000

Respiratory Therapy Patient Kardex Index Cards

3 years after most recent discharge

1150-0000

Antibiotic Sensitivity Patterns - Graph

5 years

1151-0000

Barbiturate Records

5 years

1152-0000

Narcotic Books and Records

5 years

1153-0000

Patient Profile Record System

5 years from date of last entry in the profile record

1154-0000

Pharmacist/Intern Signature and/or Initial Identification

5 years after termination of employment

1155-0000

Pharmacy Requisition

6 years

1156-0000

Prescription Books   

5 years after last entry

Professional Services - Housekeeping

1200-0000

Daily Patient Interview Form

3 years

1201-0000

Daily Supervisor’s Report

3 years

1202-0000

Linen Inventory

3 years

1203-0000

Patient Dismissal Notice to Housekeeping

3 years

1204-0000

Project List - Work Order

3 years

1205-0000

Supply Inventory

3 years

1206-0000

Weekly Inspection Report

3 years

Professional Services - Patient Management

1250-0000

Appeals
Hospital costs appeals filed by patients

6 years after final settlement or payment

1251-0000

Diagnosis Related Group Analysis Files
Includes a financial and clinical analysis of services provided

6 years

1252-0000

Incident Reports

1252-0001

Incident Reports (Original)

6 years after incident, final settlement or payment

1252-0002

Incident Reports (Copies)

Periodic Review

1253-0000

Patient Complaint Files and Litigation Case Files

6 years after final settlement or payment

1254-0000

Social Services Discharge Planning File (Copy)
Includes individual patient worksheet and referral notes. Original maintained in medical records.

3 years after discharge

Professional Services - Radiology

1300-0000

Annual reports of Radiation Surveys

Permanent

1301-0000

Daily Calibration Standards Check in Dose Calibrator

10 years

1302-0000

Daily Check of Incoming and Outgoing Materials

2 years

1303-0000

Daily Dose Report per Patient

2 years

1304-0000

Daily Flood Check - Nuclear Camera Check

10 years

1305-0000

Daily Personnel Monitoring Report

10 years after termination of employment

1306-0000

Daily Radiation Monitoring Report

10 years

1307-0000

Daily Radiation Survey - Area of Injection

10 years

1308-0000

Daily Survey Meter Check

2 years

1309-0000

Equipment Quality Testing - Monthly Report

10 years

1310-0000

Individual Monthly Badge Report

10 years

1311-0000

Individual Report of Radiation exposure (JCAHO)

10 years after termination of employment

1312-0000

License Files - Nuclear Regulatory Commission (NRC)
Includes federal and state licenses required for the operation of radiation emitting equipment.

10 years after expiration

1313-0000

Nuclear Radiation Technologist Certification

10 years after expiration

1314-0000

Patient Cards

10 years after inactive

1315-0000

Patient Sign-In Roster

3 years after final entry

1316-0000

Register of all Radiation Producing Equipment

10 years after disposal of equipment

1317-0000

Semiannual Survey of Calibration Standards Re-Tested

3 years

1318-0000

Semiannual Survey Report of Meters Recalibrated and Re-Tested

3 years

1319-0000

Weekly Bar Phantom Check Report - Calibration Report

3 years

1320-0000

Weekly Radiation Survey of Entire Radiology Department

3 years

1321-0000

Work Schedules

6 years

1322-0000

X-Ray Films

5 years

1323-0000

X-Ray Interpretation (Copy)
Original maintained in Medical Record

5 years

1324-0000

X-Ray Technician Certification

10 years after expiration

1325-0000

Inventory of all Sealed Radioactive Materials

3 years

1326-0000

Sealed Source Records - Leak Tests

3 years

1327-0000

Unsealed Source Records - Area Contamination Wipe Tests

3 years

1328-0000

Survey of Radioactive Material Received

3 years

1329-0000

Survey of Waste Generated in Controlled Areas

3 years

1330-0000

Nuclear Medicine Dose Calibrator - Constancy Test, Linearity Test, Accuracy and Geometry Test

3 years

1331-0000

Nuclear Medicine Radiopharmaceutical Dosage - Dose Determination Test

3 years

1332-0000

Nuclear Medicine Imaging Service - Uniformity Test and Resolution Test

3 years

1333-0000

Nuclear Medicine Well Counter - Constancy Test

3 years

   Back to Table of Contents

Finance

1350-0000

Census

1350-0001

Census - Annual

6 years

1350-0002

Census - Monthly and Quarterly

3 years

1350-0003

Census - Weekly

1 year

1350-0004

Census - Daily

1 month

1350-0005

Census (Copies)

As updated

1351-0000

Daily Bed Count

3 years

Finance - Admissions/Registration

1400-0000

Admission Register/Log

3 years

1401-0000

Daily Reservation Sheets   

1 year

Finance - Budget and Reimbursement

1450-0000

Annual Hospital Rate Submission

20 years

1451-0000

Audit Reports - Annual

Permanent

1452-0000

Bank Records
Includes: statements, cancelled checks, deposit slips, and reconciliations, etc.

6 years

1453-0000

Bids

6 years

1454-0000

Budget Workpapers

6 years

1455-0000

Hospital Rate Appeals

7 years after settlement

1456-0000

Medicare Cost Reports

3 years

1457-0000

Monthly Detail Analysis Report

1457-0001

Monthly Detailed Analysis Report (Original)

3 years

1457-0002

Monthly Detail Analysis Report (Copies)

As updated

Finance - Accounting

1500-0000

Accounts Payable Distribution Report

6 years

1501-0000

Cancelled Checks and Stubs

6 years

1502-0000

Charge Slips

6 years

1503-0000

Check Register

6 years

1504-0000

Earnings and Deductions Register

6 years

1505-0000

Equipment Ledger - Inventory

3 years after update

1506-0000

Ledgers

1506-0001

Ledgers - General

Permanent

1506-0002

Ledgers - Subsidiary

10 years

1507-0000

Payroll Distribution List
List payroll distribution breakdown by department and person.

6 years

1508-0000

Payroll Register

1508-0001

Payroll Register (Master)

Permanent

1508-0002

Payroll Register (Copies)

3 years

1509-0000

Phone Bills and Toll Listing

3 years

1510-0000

Purchase Order Listing (Monthly)

6 years

1511-0000

Quarterly Reports for State and Federal Deductions

6 years

1512-0000

Tax Withholding Forms (W-2, W-4), etc.

3 years

1513-0000

Timesheets  

6 years

Finance - Patient Billing

1550-0000

Assessment Reports of Patients’ Accounts - Monthly Status Report

3 years

1551-0000

Cash Receipts

6 years

1552-0000

Departmental Allowance Reports

3 years

1553-0000

Insurance Carrier’s Vouchers

6 years

1554-0000

Monthly Agency Payment Report

3 years

1555-0000

Monthly Payment Register

6 years

1556-0000

Monthly Trial Balance

3 years

1557-0000

Patient Billing Files
Includes: Admission Form (Copy), verification documentation, insurance company correspondence, detailed billing list, and uniform bill.

6 years after final action or write-off

1558-0000

Record of Refund  

6 years

Finance - Materials Management/Procurement

1600-0000

Cost Containment Report - Cost Savings Report

1600-0001

Cost Containment Report - Annual

Permanent

1600-0002

Cost containment Report - Monthly

3 years

1601-0000

Itemized Listing of Receivables

1601-0001

Itemized Listing of Receivables - Monthly

3 years

1601-0002

Itemized Listing of Receivables - Daily

1 year

1602-0000

Purchase Orders/Purchase Requisitions

1602-0001

Purchase Orders/Purchase Requisitions (Record Copy)

6 years

1602-0002

Purchase Orders/Purchase Requisitions (Accounting Copy)

1 year

1602-0003

Purchase Orders/Purchase Requisitions (Additional Copies)

1 year

1603-0000

Subsidiary Ledger  

10 years

Transportation Services

1650-0000

Escort Assignment Slip

2 years

1651-0000

Transport Travel Log

3 years

1652-0000

Vehicle Maintenance File

6 years after disposal of vehicle

Medical Records

1700-0000

Fetal Monitoring Strips

23 years

1701-0000

Medical Records - Inpatient/Outpatient
Includes all disciplines.

1701-0001

Individual Patient Charts
Contains: bedside notes, admission form, medical chart, medication prescribed, emergency room report, Ambulatory Care Services Report, and all required documentation according to licensing and accreditation bodies.

10 years after most recent discharge or age 23, whichever is later

1701-0002

Discharge Summary Sheet

20 years

1701-0003

Medical Records of Deceased Individuals

6 years

1702-0000

Subpoenas and Related Correspondence

3 years from final action

Security

1750-0000

Daily Incident Log/Daily Blotter

3 years after final entry

1751-0000

Incident Reports  

3 years

Maintenance

1800-0000

Air Conditioning/HVAC Filter Change Log

3 years after final entry

1801-0000

Annual Boiler Inspection Report

3 years

1802-0000

Building Plans and Specifications

Permanent

1803-0000

Conductivity Testing of Electrical Receptacles - Annual

3 years

1804-0000

Emergency Generator Log

3 years after final entry

1805-0000

Fire Prevention Checklist

1805-0001

Fire Prevention Checklist - Annual Report

6 years

1805-0002

Fire Prevention Checklist - Quarterly Report

3 years

1806-0000

Fire/Electrical Safety Training Programs
Includes: course outlines, handouts, and brochures, etc.

3 years after update

1807-0000

Freezer Temperature Reading Log

3 years after final entry

1808-0000

Heliport Annual License

3 years after expiration

1809-0000

Monthly Fire Drill Report

3 years

1810-0000

Operating Engineer’s Daily Log

6 years after final entry

1811-0000

Preventive Maintenance Duct Cleaning Report

3 years

1812-0000

Quarterly Inspection Report of Operating Room Equipment

3 years

1813-0000

Quarterly Sewer Cleaning Inspection Report

6 years

1814-0000

Sprinkler Inspection Semiannual Report

3 years

1815-0000

Trash Incineration Daily Report
Consists of: statistical report on amount of trash incinerated, boxes of needles, hazardous waste, medical waste, weight and temperature.

6 years

1816-0000

Work Orders/Work Requests

1816-0001

Work Orders/Work Requests (Original)

6 years

1816-0002

Work Orders/Work Requests (Copies)

3 years

   Back to Table of Contents

Medicine Division

1850-0000

Daily Consultations with Other Departments

2 years

Concerning Medication Given to Patients

1851-0000

Explorations and Discharges - Records of Results of Medications Given (Research)

Permanent

1852-0000

Residency Certificates

Permanent

1853-0000

Student Applications - Unsuccessful

3 years

   Back to Table of Contents

Infection Control

1900-0000

Antibiotic Audit Survey Report

3 years

1901-0000

Environmental Sanitation Inspection Report

3 years

1902-0000

Immediate/Infection Report Form Received From Nurses/Doctor

3 years

1903-0000

Weekly Report of Antibiotic Orders

5 years

   Back to Table of Contents

Quality Assurance

1950-0000

Program Assessment/Evaluation Reports - Periodic/Program Audit Reports

3 years

1951-0000

Quality Assurance Annual Evaluations

Permanent

1952-0000

Quality Assurance Investigative Case Files

6 years after problem is resolved

1953-0000

Quality Assurance Reports
Contains clinical disciplines and ancillary departments - monthly and quarter summary reports.

6 years

   Back to Table of Contents

Program Evaluation/Joint Commission Accreditation Health Organizations (JCAHO)

2000-0000

Facility and Program Evaluation Inspection Reports
Includes: goals and objectives, quarterly progress reports, final progress reports evaluations, and surveys. Evaluations are conducted every three (3) years.

6 years

2001-0000

Problem Identification Summary
Used to indicate and track problems

6 years

2002-0000

Special Reporting and Evaluation Reports

Permanent

   Back to Table of Contents

Utilization

2050-0000

Emergency Services Review

3 years

2051-0000

Federal and Non-Federal Termination of Benefits Letters

6 years

2052-0000

Hospital Patient Stay Review
Includes inappropriate length of stay letters and replies

3 years

2053-0000

Investigative Case File

6 years after problem is resolved

2054-0000

Patient Care Monitoring Forms (Evaluation)

3 years after discharge of patient

2055-0000

Patient Discharge Forms - Billing
Includes: insurance carrier coverage forms, denial of benefits letters, charge slips, and physicians’ review recommendation.

6 years

2056-0000

Public Welfare Certification of Coverage

6 years

   Back to Table of Contents

Rehabilitation Services

2100-0000

Attendance Sign-In Book

6 years

2101-0000

Charge Slips

3 years

2102-0000

Combined Activity Analysis

6 years

2103-0000

Contracts/Agreements for Services

6 years after termination

2104-0000

Daily Progress Statistical Report
Lists: patients, dates of visits, length of time, classification or degree of difficulty patients not attending, discharges, and charges.

3 years

2105-0000

Education Program
Includes: attendance sheet, agenda, and bank account

6 years

2106-0000

Electromylogram (E.M.G.)

2106-0001

Electromylogram (E.M.G.) - Diagnostic Interpretation Report

10 years or age 23, whichever is later

2106-0002

Electromylogram (E.M.G.) - Graphs

5 years

2107-0000

Inventory and Release Form for Physical Therapy Equipment

6 years

2108-0000

Patient Medical Record - Outpatient
Includes: medical chart, progress notes, orders, and admission form.

10 years from most recent discharge or age 23, whichever is later

2109-0000

Patient Medical Discharge Summary - Outpatient

20 years

2110-0000

Patient Kardex

As updated

2111-0000

Speech Therapist Licenses (Copies)

6 years after termination of employment

2112-0000

Training Request

3 years after completion of training

2113-0000

Work Schedule

6 years

Back to Table of Contents