Mississippi Medical/Facility Records Retention Schedule.doc.doc

HCA Record Retention Schedule – Medical/Facility Records

State of Mississippi

For general accounting and payroll records, please reference Accounting Retention Schedule. For general personnel records, please reference Human Resources Retention Schedule.For general administrative records, please reference Administrative Retention Schedule.For general legal records, please reference Legal Retention Schedule.For general information systems records, please reference Information Systems Retention Schedule.For patient accounting records, please reference Patient Account Services Schedule.

The record retention listed is for the official record copy. Duplicates should be retained until obsolete, superseded, or administrative value is lost. The official record copy may be in hardcopy, electronic, and/or microform format. If the hardcopy is the original record and is scanned into an imaging system, the hardcopy should be retained for the duration of the retention until further notice.

Record Series Code Record Series Title & Description Legal Citation

Total Retention

MS-MED-10-01 Administrative OfficesAnnual Reports to State Departments of Health Minimum

Standards for Hospitals 201.1

Permanent

MS-MED-10-02 Administrative OfficesBirth Records to Local Government

Records consist of copies of vital birth records and certificates filed with state registrar of vital statistics.

Permanent

MS-MED-10-04 Administrative OfficesDaily Census

Daily patient census data.

CY+5 years

NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health RegulationsLEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value

Approved: April 20, 2001Revised: September 10, 2003

1 of 31


Total Retention

MS-MED-10-05 Administrative OfficesHospital Permits

Required permits to operate a hospital.

MS Code § 41-9-11; MS Code §

41-9-81

Retain Until Suspended or

Revoked

MS-MED-10-06 Administrative OfficesCommunicable Disease Reports

Reports related to communicable diseases.

MS Code § 41-23-1 (4), (5)

CY+3 years

MS-MED-10-07 Administrative OfficesMedical Staff Files

Medical staff files including certification, credentials, complaints and continuing medical education records.

Minimum Standards for Hospitals 501

Life of Hospital

MS-MED-10-08 Administrative OfficesConstitution and Medical Staff Bylaws

Records documenting the terms, conditions, and procedures by which the facility will operate.

MS Code § 41-9-81; Minimum Standards for Hospitals 301,

406, 502.1, 506.1

Life of Hospital

MS-MED-10-09 Administrative OfficesMinutes of Board of Directors, Executive Committee, Medical Staff

Records detailing the proceedings of board of directors, executive committee, and medical staff meetings. For department, committee, or project meetings use ADM-90-09.

MS Code § 41-9-81; Minimum Standards for Hospitals 504

Life of Hospital

MS-MED-10-10 Administrative OfficesDeath Records to Local Government

Copies of death records required by local government.

MS Code § 41-23-1(2), (3)

Permanent

MS-MED-10-11 Administrative OfficesDeath Records

Records that track the transfer of corpses from the hospital to outside locations.

CY+3 years

MS-MED-10-12 Administrative OfficesStatistics on Admissions, Services, and Discharges

Statistical data compiled into various reports detailing patient admissions, services rendered, transfers, leave of absences, and discharges.

42 USC 1395cc(a)(1)(I) (ii)

CY+6 years

MS-MED-10-14 Administrative OfficesAdmissions/Discharges Register CY+6 years



2 of 31


Total Retention

Official register of all patient admissions and discharges.

MS-MED-10-16 Administrative OfficesMedical Equipment Logs

Records detailing the type, model, location, and usage of medical equipment.Includes maintenance, scheduled function checks, and instrument calibration performed in accordance with the manufacturer’s instructions.

CY+3 years

MS-MED-10-20 Administrative OfficesAccreditation Surveys and Reports

Records related to accreditation surveys and results. Includes inspection reports by accrediting institutions, notices of corrections, correction reports, activity calendars, in-house surveys, and testing done prior to the actual accreditation survey.

MS Code § 41-63-21

5 years After Next

Accreditation is Issued

MS-MED-10-22 Administrative OfficesMedical Directives, Policy and Procedure Manuals

Directives, policies, and procedures for facility operations. Includes emergency code procedures and cards.

7 years After SUP

MS-MED-10-24 Administrative OfficesTraining Programs

Records related to classes and training programs provided to patients and customers by clinical staff. Includes Lamaze, CPR, and first aid.

ACT+3 years

MS-MED-10-25 Administrative OfficesEmployee Training

Records related to employee training provided on hazards and use of pesticides.

3 years After Separation From

Job

MS-MED-10-26 Administrative OfficesVolunteer Records

Records related to work activities of volunteers at facilities. Includes work schedules, location, and duties performed.

2 years After Termination

MS-MED-10-28 Administrative OfficesDeceased Patients Property Disposition

Records relating to the disposition of deceased patient’s personal property.

CY+3 years



3 of 31


Total Retention

MS-MED-10-29 Administrative OfficesPatient Personal Property Inventory 3 years After

DischargeMS-MED-10-30 Administrative Offices

Inspection Reports

Reports of inspection by local, state, or federal agents.

10 CFR 30.51 CY+5 years

MS-MED-10-32 Administrative OfficesOSHA Records

Records include logs, summaries, and OSHA forms 102/102a.

29 CFR 1904.6 5 years

MS-MED-10-34 Administrative OfficesPastoral Visitation Log CY+3 years

MS-MED-12-02 Housekeeping RecordsAutoclave Records Adopted Standards

for the Regulation of Medical Waste

II.B.5

2 years

MS-MED-12-04 Housekeeping RecordsCheckout, Transfer, Isolation Records 2 years

MS-MED-12-06 Housekeeping RecordsCleaning Records Minimum

Standards for Hospitals 1502

2 years

MS-MED-12-08 Housekeeping RecordsLinen Poundage Report 2 years

MS-MED-12-10 Housekeeping RecordsExterminator Records CY+5 years

MS-MED-30-02 Dietary RecordsFood Costs

Records related to the purchase and cost of food and food services.

CY+5 years

MS-MED-30-04 Dietary RecordsMenus

Records related to food service that include menus, food lists, name of dietitian, date, average portion size, schedule of time, and length of foodservice.

1 year

MS-MED-30-05 Dietary Records



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Total Retention

Inspection Reports Minimum Standards for

Hospitals 1302.1

Retain 1 year After SUP

MS-MED-30-06 Dietary RecordsDietary Recipe Records

Standardized dietary recipe records used in the preparation of patient meals by the kitchen staff. Includes a nutritional analysis, ingredients list, and serving size notation.

Minimum Standards for

Hospitals 1303

AV

MS-MED-30-08 Dietary RecordsDietician Counseling Summaries

Annual summaries provided by a nutritionist or dietitian that evaluate the menus, sanitation, policies and procedures, and recommend modifications for the food preparation and service.

2 years

MS-MED-30-10 Dietary RecordsInservice Training Records Minimum


ACT+3 years

MS-MED-30-12 Dietary RecordsBacteriological Testing of Ice 2 years

MS-MED-30-14 Dietary RecordsMeal Counts 1 year

MS-MED-40-02 Clinic RecordsAppointment Books

Patient appointment books that record the appointment time and patient name.

CY+3 years

MS-MED-40-04 Clinic RecordsEncounter Statistics

Statistical data for clinic encounters.

CY+5 years

MS-MED-40-06A Clinic RecordsSocial Service Confidential Case Histories-Adults

Clinic patients social service case histories.

MS Code § 41-9-69 (1); Minimum


Adults of Sound Mind 10 years

After Discharge, Patients

Discharged at Death 7 years

MS-MED-40-06B Clinic Records



5 of 31


Total Retention

Social Service Confidential Case Histories-Minors

Clinic patients social service case histories.



Minors – Period of Minority Plus 7 years, But Not

to Exceed 28 years

MS-MED-40-08A Clinic RecordsWelfare Agency Records-Adults

Clinic records related to welfare agencies.

MS Code § 41-9-69 (1)




MS-MED-40-08B Clinic RecordsWelfare Agency Records-Minors

Clinic records related to welfare agencies.

MS Code § 41-9-69 (1)


to Exceed 28 years

MS-MED-50-02 Laboratory, Therapy, and ImagingBlood Bank – Adverse Reactions to Transfusions

Records related to adverse reactions to blood transfusions.

21 CFR 606.160 5 years After Processing or 6 Months After

the Latest Expiration Date

for the Individual Product,

Whichever is Longer

MS-MED-50-03 Laboratory, Therapy, and ImagingBlood Bank – General Records

Records related to information concerning sterilization of supplies and reagents, responsible personnel, errors and accidents, maintenance of equipment and the physical plant, expiration dates of supplies and reagents, and logs which indicate on-hand inventory and notices of emergency shortages.


Hospitals 1910.7; 21 CFR 606.160

5 years After Processing or 6 Months After

the Latest Expiration Date, If There is No

Expiration Date Records are

Retained Permanently

MS-MED-50-04 Laboratory, Therapy, and Imaging



6 of 31


Total Retention

Blood Bank – Blood Donor Records

Records related to blood donors including histories, examinations, consent, reactions, donor selection, results of required tests performed on plasmpheresis and cytopheresis donors, permanent and temporary deferrals, investigation and follow-up, therapeutic bleedings, immunization, and blood collection.






Blood Bank – ABO and RH Types

Records related to type testing of blood.





MS-MED-50-07 Laboratory, Therapy, and ImagingBlood Bank – Quality Control

Records related to the calibration and standardization of equipment, performance checks, periodic check of sterile technique, and periodic tests of the capacity of shipping containers to maintain the proper temperature.






Blood Bank – Blood Test Results

Records related to blood test results including interpretations and release data for compatibility testing.





MS-MED-50-10 Laboratory, Therapy, and Imaging Blood Bank – Final Disposition of Blood and Components Minimum 5 years After



7 of 31


Total Retention

Records related to the final disposition of blood and blood components.Standards for

Hospitals 1910.7; 21 CFR 606.160

Processing or 6 Months After




MS-MED-50-12 Laboratory, Therapy, and ImagingBlood Bank – Refrigeration and Blood Inspection Records

Records detailing blood inspection and refrigeration.





MS-MED-50-14 Laboratory, Therapy, and ImagingBlood Bank – Transfusion Request Records

Transfusion requests received by the blood bank.





MS-MED-50-15A Laboratory, Therapy, and ImagingEchocardiogram Tracings-Adults

Patient echocardiogram tracing. Includes actual strips generated by echocardiogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record.

MS Code § 41-9-69 (1)




MS-MED-50-15B Laboratory, Therapy, and ImagingEchocardiogram Tracings-Minors

Patient echocardiogram tracing. Includes actual strips generated by

MS Code § 41-9-69 (1)




8 of 31


Total Retention

echocardiogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record.

to Exceed 28 years

MS-MED-50-16A Laboratory, Therapy, and ImagingElectrocardiogram Tracings-Adults

Patient electrocardiogram tracings. Includes actual strips generated by electrocardiogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record.

MS Code § 41-9-69 (1)




MS-MED-50-16B Laboratory, Therapy, and ImagingElectrocardiogram Tracings-Minors

Patient electrocardiogram tracings. Includes actual strips generated by electrocardiogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record.

MS Code § 41-9-69 (1)


to Exceed 28 years

MS-MED-50-18A Laboratory, Therapy, and ImagingElectroencephalogram Tracings-Adults

Patient electroencephalogram tracings. Includes actual strips generated by electroencephalogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record.

MS Code § 41-9-69 (1)




MS-MED-50-18B Laboratory, Therapy, and ImagingElectroencephalogram Tracings-Minors

Patient electroencephalogram tracings. Includes actual strips generated by electroencephalogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record.

MS Code § 41-9-69 (1)


to Exceed 28 years

MS-MED-50-19A Laboratory, Therapy, and ImagingElectromyograms Tracings-Adults

Patient electromyogram tracings. Includes actual strips generated by electromyogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record.

MS Code § 41-9-69 (1)




MS-MED-50-19B Laboratory, Therapy, and ImagingElectromyograms Tracings-Minors

Patient electromyogram tracings. Includes actual strips generated by

MS Code § 41-9-69 (1)




9 of 31


Total Retention

electromyogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record.

to Exceed 28 years

MS-MED-50-20 Laboratory, Therapy, and ImagingRadioisotopes

Records related to the receipt, transfer, use, storage, delivery, disposal, and overexposure of radioisotopes.

MS Code § 45-14-19 (1) (a); Mississippi

Radiological Health

Regulations 801.A.4; 10 CFR

30.51

5 years

MS-MED-50-21 Laboratory, Therapy, and ImagingLaboratory Test Requisitions

Requisitions authorizing a laboratory to perform tests on a sample.

42 CFR 493.1105 2 years

MS-MED-50-22A Laboratory, Therapy, and ImagingTherapy Treatment Records-Adults

Records related to therapy treatments that are not duplicated in the patient health records. May include occupational, physical, speech, and inhalation therapy.






MS-MED-50-22B Laboratory, Therapy, and ImagingTherapy Treatment Records-Minors

Records related to therapy treatments that are not duplicated in the patient health records. May include occupational, physical, speech, and inhalation therapy.




to Exceed 28 years

MS-MED-50-23 Laboratory, Therapy, and ImagingFinal Test Reports – Pathology/Histology/Cytology

Laboratory copies of test results and preliminary reports specific to pathology, histology and cytology. Includes histology and pathology specimen logs and slides.

42 CFR 493.1109; 42 CFR 493.1257

10 years After Date of

Reporting

MS-MED-50-24 Laboratory, Therapy, and ImagingAutoclave/Sterile Supply Records

Records related to autoclave/sterile supply.

Adopted Standards for the Regulation of Medical Waste

II.B.5

2 years

MS-MED-50-25 Laboratory, Therapy, and ImagingSterilizers/Bacteriological Tests 3 years



10 of 31


Total Retention

Records related to sterilizers and monthly bacteriological tests. Includes recording charts, chemical indicators, Bonne-Dick tests, readings from jacket pressure gauge, and chamber pressure gauge.

MS-MED-50-26 Laboratory, Therapy, and ImagingPatient Testing Reports – Immunohematology/Histocompatibility

Immunohematology and histocompatibility specific reports related to the processing, testing, and reporting of patient specimens to assure the accuracy of the testing.

42 CFR 493.1109 5 years

MS-MED-50-28 Laboratory, Therapy, and ImagingLaboratory Reports – Complete

Reports documenting each step in the processing, testing, and reporting of patient specimens to assure the accuracy of the testing.

42 CFR 493.1109 5 years

MS-MED-50-30 Laboratory, Therapy, and ImagingPatient Testing Reports – Laboratory Copies

Reports documenting each step in the processing, testing, and reporting of patient specimens to assure the accuracy of testing, and the loan or referral of slides to another laboratory.


Hospitals 1906.1; 42 CFR 493.1101

2 years

MS-MED-50-32 Laboratory, Therapy, and ImagingTissue Tracking System Records

Records related to the receipt and disposition of all organs and tissues transplanted within the hospital.


Hospitals 1908.4

Permanent

MS-MED-50-33A Laboratory, Therapy, and ImagingSpecimens-Wet Tissue 42 CFR

493.1259 (b)7 days After Sign Out

MS-MED-50-33B Laboratory, Therapy, and ImagingSpecimens-Paraffin Blocks 42 CFR

493.1259 (b)2 years

MS-MED-50-33C Laboratory, Therapy, and ImagingSpecimens-Slides

42 CFR 493.1257(g)

5 years

MS-MED-50-33D Laboratory, Therapy, and ImagingSpecimens-Histopathology Slides 42 CFR

493.1259 (b)10 years

MS-MED-50-34 Laboratory, Therapy, and ImagingSpecimen Logs 10 years



11 of 31


Total Retention

Individual department specimen logs documenting the receipt of specimens to the lab, procedures performed, results obtained, and the disposition of the specimen. It does not become part of the patient’s medical file or the tissue tracking system records.

MS-MED-50-35A Laboratory, Therapy, and ImagingBone Marrow Test Reports-Adults

Records related to the testing of bone marrow.

MS Code § 41-9-69 (1)




MS-MED-50-35B Laboratory, Therapy, and ImagingBone Marrow Test Reports-Minors

Records related to the testing of bone marrow.

MS Code § 41-9-69 (1)


to Exceed 28 years

MS-MED-50-36 Laboratory, Therapy, and ImagingTest Procedures

Copies of each test procedure with the date of its initial use. May include the test methodology and results, who performed the test, possible side effects, and any necessary equipment.

5 years

MS-MED-50-37 Laboratory, Therapy, and ImagingRequests for Tests

Includes oral, written, and electronic requests for tests.


Hospitals 1905.2; 42 CFR 493.1105

2 years

MS-MED-50-38 Laboratory, Therapy, and ImagingTest Procedures – Discontinued

Records of each test procedure with the dates of its initial use and discontinuance. May include the test methodology and results, who performed the test, possible side effects, and any necessary equipment.

4 years After Procedure is Discontinued

MS-MED-50-39 Laboratory, Therapy, and ImagingTest Procedures – Errors

Records include original and corrected reports.

42 CFR 493.1219(d)(3)

5 years

MS-MED-50-40 Laboratory, Therapy, and ImagingEchocardiogram Video Tapes 5 years



12 of 31


Total Retention

Videotapes created during an echocardiogram.

MS-MED-50-41 Laboratory, Therapy, and ImagingVideo Tapes of Diagnostic Tests

Videotapes created for other diagnostic tests not listed elsewhere.

5 years

MS-MED-50-42A Laboratory, Therapy, and ImagingScreening Procedures-Adults

Records relating to screening procedures for health risk appraisal, blood pressure, blood pressure referral, vision, hearing and speech, diabetics screening, syphilis serology, gonorrhea, and other laboratory screenings and tests.

MS Code § 41-9-69 (1)




MS-MED-50-42B Laboratory, Therapy, and ImagingScreening Procedures-Minors

Records relating to screening procedures for health risk appraisal, blood pressure, blood pressure referral, vision, hearing and speech, diabetics screening, syphilis serology, gonorrhea, and other laboratory screenings and tests.

MS Code § 41-9-69 (1)


to Exceed 28 years

MS-MED-50-44 Laboratory, Therapy, and ImagingHIV Test Results

Records consist of anonymous test results for HIV.

42 CFR 493.1109 2 years After Date of

Reporting

MS-MED-50-46A Laboratory, Therapy, and ImagingHIV Test Results-Adults

Records consist of seropositive and seronegative confidential test results for HIV.

MS Code § 41-9-69 (1)




MS-MED-50-46B Laboratory, Therapy, and ImagingHIV Test Results -Minors

Records consist of seropositive and seronegative confidential test results for HIV.

MS Code § 41-9-69 (1)


to Exceed 28 years

MS-MED-50-48A Laboratory, Therapy, and Imaging



13 of 31


Total Retention

Screenings for Infant Genetic or Metabolic Disorders-Copies

Copies of test results for infant genetic or metabolic disorders. Originals are maintained in the patient’s medical record.

MS Code § 41-9-69 (1)

Copies 2 years

MS-MED-50-48B Laboratory, Therapy, and Imaging-OriginalsScreenings for Infant Genetic or Metabolic Disorders-Originals

Original test results for infant genetic or metabolic disorders. Originals are maintained in the patient’s medical record.

MS Code § 41-9-69 (1)

Originals Period of Minority Plus 7 years, But Not

to Exceed 28 years

MS-MED-50-50 Laboratory, Therapy, and ImagingRadiology Utilization Logs

Logs documenting each source of radiation, the make and model number, storage container, identity of the radiographer, location, and date of its use.

5 years

MS-MED-50-52 Laboratory, Therapy, and ImagingPerformance Records

Reports issued on each laboratory's performances for the individual Medicare, Medicaid, and CLIA-licensed specialty or sub-specialty of service after a proficiency test is performed.

42 CFR 493.903 5 years

MS-MED-50-54 Laboratory, Therapy, and ImagingRadiation Equipment – Minor Maintenance

Records related to the minor maintenance, daily function checks, routine and package surveys, and instrument calibration performed in accordance with the manufacturer's instructions on a Facility’s testing equipment.

2 years After Completion of

Calibration

MS-MED-50-55 Laboratory, Therapy, and ImagingTesting – Unsealed Sources

Records related to the testing of unsealed sources of radiation by radiology for leaks or contamination.

Mississippi Radiological

Health Regulations

801.C.22 (d) (3) (iv)

3 years From the Date of the

Recorded Event or Until the Device is

Transferred or Disposed of

MS-MED-50-56 Laboratory, Therapy, and ImagingTesting – Sealed Sources

Records related to the testing of sealed sources of radiation by radiology for leaks or contamination.


Health Regulations

801.C.22 (d) (3) (iv)

3 years From the Date of the

Recorded Event or Until the Device is

Transferred or Disposed of




14 of 31


Total Retention

Sealed Radiation Sources – Inventory

Records related to staff conducting physical inventories to account for all sealed radiation sources received or possessed under an appropriate license.

2 years

MS-MED-50-60 Laboratory, Therapy, and Imaging Inspections – Radiology

Records related to federal, state, and/or consulting physicist's inspections of the radiological services area. Includes tests on protective equipment such as aprons, gloves, and shields, and any actions taken to correct the identified deficiencies.


Hospitals 2102.3; Mississippi

Radiological Health

Regulations 801.A.5

5 years

MS-MED-50-62 Laboratory, Therapy, and ImagingTesting Entry Control Devices

Records related to the testing of the entry control devices to secured areas housing high levels of radiation. Includes date, time and results of each test.

2 years

MS-MED-50-64 Laboratory, Therapy, and ImagingRadiation Protection Program – Audits

Records related to the audits or reviews on the Radiation Protection Program.

3 years

MS-MED-50-66 Laboratory, Therapy, and ImagingRadiation Protection Program

Records documenting the prevention of unnecessary radiological exposure to humans and the environment.


Health Regulations

801.C.24 (h) (3)

5 years

MS-MED-50-67 Laboratory, Therapy, and ImagingRadiation Protection Program – Misadministration

Records documenting the misadministration of dosages including wrong patient, dosage differences from prescribed dosage, and wrong mode of treatment.


Health Regulations

801.A.7

5 years

MS-MED-50-68 Laboratory, Therapy, and Imaging Credential License and Certification Records

Credentials, licenses, and certifications of each person providing diagnostic and therapeutic radiation, imaging, and nuclear medicine services including formal training, on the job education, and continuing educational credits.

7 years After Separation or

Termination of Employment

MS-MED-50-70 Laboratory, Therapy, and ImagingPlanned Special Exposure 1 year After



15 of 31


Total Retention

Records documenting planned and authorized radiological exposure. Termination or Expiration of

LicenseMS-MED-50-72 Laboratory, Therapy, and Imaging

Environmental Exposure

Records documenting the results of measurements and calculations used to evaluate the release of radioactive effluents into the environment.

3 years

MS-MED-50-74 Laboratory, Therapy, and Imaging Radiation Monitoring Records – Human Exposure

Records related to the monitoring of annual doses received by individuals, the doses received during planned special exposures, accidents, and emergency conditions. Includes adults and minors who receive in excess of their limitations in a single year and individuals entering a high or very high radiation area. May include surveys of radiation for determining an individual’s dose from external sources.

MS Code § 45-14-19 (1) (b); Mississippi

Radiological Health

Regulations 801.J.13 (b)

3 years

MS-MED-50-76 Laboratory, Therapy, and Imaging Radiation Detection Instrumentation

Records related to the calibration of radiation detection instruments that measure the radiation levels in the environment, on humans, and objects. Includes dates and times of inspections, repairs, and dates in and out of service.


Calibration

MS-MED-50-78 Laboratory, Therapy, and ImagingRadiation Monitoring Records – Radioactive Materials

Records documenting the results of calibrations for packages received that contain radioactive materials. Includes the date and time a package was received, the time and date of calibration, the results and levels of the test, the name of the person who performed the test.


Calibration

MS-MED-50-80 Laboratory, Therapy, and ImagingRadiology Surveys

Records related to surveys to evaluate radiation levels, concentrations or quantities of radioactive materials, and potential radioactive hazards that could be present. Includes surveys of physical radiation for the purpose of determining whether each sealed source is in its shielded position prior to securing the radiographic device, storage container, or source changes in a storage area. The entire device is surveyed including the source guide tube.

3 years

MS-MED-50-81 Laboratory, Therapy, and ImagingNuclear Medicine Reports 5 years



16 of 31


Total Retention

Includes nuclear medicine interpretations, consultations, and procedures.

MS-MED-50-82 Laboratory, Therapy, and Imaging Images of Computed Tomography

Images of spot checks for computed tomography x-ray systems.

Until a New Dose

Measurement is Performed

MS-MED-50-84 Laboratory, Therapy, and Imaging Therapeutic X-Ray Systems of less than 1MeV

Records of the calibrations of the therapy system.


Calibration

MS-MED-50-86 Laboratory, Therapy, and Imaging Therapeutic X-Ray Systems of more than 1MeV

Records of the calibrations of the therapy system and of the dosimetry system.


Calibration

MS-MED-50-88 Laboratory, Therapy, and Imaging Mammograms

Original mammograms.

10 years

MS-MED-50-90 Laboratory, Therapy, and Imaging Mammogram File – Single Visit

X-ray film that is the ONLY mammogram taken. Retention is for the actual film not the radiologist's interpretation of film. The interpretation is part of the Patient Medical Record. For more than one mammogram see MS-MED-60-06.

10 years

MS-MED-50-92 Laboratory, Therapy, and Imaging Mammography – Quality Assurance

Records related to the quality assurance for mammography systems. Includes annual review of quality assurance program, documentation of equipment monitoring, checks of quality control items, and any necessary corrections.

3 years

MS-MED-50-94 Laboratory, Therapy, and Imaging Mammography Facility – Complaint Records

Complaints filed by employees or patients against a mammography provider and the results of the accrediting body's investigations.

7 years After Investigation




17 of 31


Total Retention

Mammography – Quality Control Surveys

Survey reports conducted annually to assure that the facility meets specified quality control and equipment standards.

3 years

MS-MED-55-02 Facility/Departmental RecordsAdministrative Files

Administrative records for individual facility records.

CY+3 years

MS-MED-55-03 Facility/Departmental RecordsInventory and Orders

Includes records of inventories of supplies ordered, maintained, and used by individual departments. For controlled substances see MS-MED-80-02.

2 years

MS-MED-55-04 Facility/Department RecordsDepartment Log Books

Log books for individual facility departments not listed elsewhere.

CY+3 years

MS-MED-55-06 Facility/Department RecordsQC Reports

Quality control reports for individual facility departments.

CY+5 years

MS-MED-55-08 Facility/Department RecordsMedical Procedure Manuals

Manuals for medical equipment and procedures that are kept within specific facility departments.

ACT+10 years

MS-MED-55-10 Facility/Department RecordsInfection Control Program Records

Records include surgical infection investigation reports, training course content and the review and evaluation of all septic isolation, and sanitation techniques used in the medical facility. Includes reports on employees who may have been exposed to a communicable disease, their work restrictions, and estimated date of reinstatement.


Hospitals 1402.3

CY+5 years

MS-MED-55-12 Facility/Department RecordsRespiratory Protection Program

Records related to Respiratory Protection Programs.

1 year After Termination or Expiration of

LicenseMS-MED-55-14 Facility/Department Records

Training and Education Records ACT+3 years



18 of 31


Total Retention

Records related to training and certification of employees, which does not include radiological, diagnostic imaging, nuclear medicine training, or nursing.

MS-MED-55-16 Facility/Department RecordsImmunohematology – Quality Control Records

Records related to the quality control of immunohematology sample processing and testing to assure that the samples were tested in the same exact manner as the regular patient samples.

21 CFR 606.160; 42 CFR 493.1221

5 years

MS-MED-55-18 Facility/Department RecordsLaboratory – Quality Control Records

Records related to the quality control of laboratory sample processing and testing to assure that the samples were tested in the same exact manner as the regular patient samples.

42 CFR 493.1221 2 years

MS-MED-55-20 Facility/Department RecordsChart Audits

Internal audits and related work-papers performed on patient charts.

1 year

MS-MED-55-22 Facility/Department RecordsIntensive Care Unit Logs

Log created and maintained by the Intensive Care Unit of a facility.

10 years

MS-MED-55-24 Facility/Department RecordsImplant Logs

Implant logs listing items implanted into patients during surgical procedures.

10 years

MS-MED-55-26 Facility/Department RecordsDelivery Room Logs

Logs detailing the names of who utilized the delivery room and when. Includes cross-references with a patient identification number for tracking or billing purposes.


Hospitals 904.15

10 years

MS-MED-55-28 Facility/Department RecordsOperating Room Schedules

Schedules of procedures performed in an operating room.

3 years

MS-MED-55-30 Facility/Department Records



19 of 31


Total Retention

X-Ray Logs

X-ray logs include name of patient, type of examination, date of the exam, and technician performing the service.

10 years

MS-MED-55-32 Facility/Department RecordsAmbulance Records

Records related to the use of an ambulance in transporting patients.

MS Code § 41-59-41

2 years

MS-MED-55-34 Facility/Department RecordsAir Ambulance Safety Committee Meeting Minutes

Records detailing the proceedings of the Air Ambulance Safety Committee.

CY+ 3 years

MS-MED-55-36 Facility/Department RecordsEmergency Communications

Records related to emergency communications received by a facility. Includes audio recordings and call logs.

MS Code § 41-59-41

2 years

MS-MED-55-38 Facility/Department RecordsSpecial Procedures Unit Logs

Records related to endoscopies and outpatient surgeries. Includes patient arrival and departure time and is documented in the patient’s health file.

CY+3 years

MS-MED-58-02 Medical Research RecordsResearch Papers – Published

Published papers from medical staff.

Permanent

MS-MED-58-04 Medical Research RecordsHuman Experimentation Records

Records related to experimental drugs and devices.

30 years Beyond Experiment,

Patient Medical Records Should be Retained for

Same Period

MS-MED-58-06 Medical Research RecordsResearch Reports

Reports related to medical research.

10 years

MS-MED-60-02 Health RecordsPatient Medical Records – Adults MS Code § 41-9-

69 (1)Adults of Sound Mind 10 years



20 of 31


Total Retention

Complete health records for adult patients. After Discharge, Patients


MS-MED-60-04 Health RecordsPatient Medical Records – Minors

Complete health records for minors.

MS Code § 41-9-69 (1)


to Exceed 28 years

MS-MED-60-05A Health RecordsPsychiatric Records-Adults

Psychiatric evaluations and treatment provided to patients.

MS Code § 41-9-69 (1)




MS-MED-60-05B Health RecordsPsychiatric Records-Minors

Psychiatric evaluations and treatment provided to patients.

MS Code § 41-9-69 (1)


to Exceed 28 years

MS-MED-60-06 Health RecordsDiagnostic Images

Diagnostic images such as x-rays. Interpretations of films are found in the Patient Medical Record. Films may cover any disease or injury and includes mammograms of returning patients.

MS Code § 41-9-69 (2)

4 years After Date of

Exposure

MS-MED-60-07 Health RecordsPatient Transfer Records

Records related to the patient transfer to and from the hospital. Information is in the Patient Medical Record.

42 USC 1395cc(a)(1)(I) (ii)

5 years From Date of Transfer

MS-MED-60-08 Health RecordsFetal Heart Monitor Records

Records related to fetal heart monitoring. Includes actual strips generated by fetal heart monitors and testing devices.

MS Code § 41-9-69 (1)


to Exceed 28 years



21 of 31


Total Retention

MS-MED-60-10 Health RecordsDisease Index, Operative Index, Physician’s Index, Diagnostic Index, Number Index

Health records indexes for disease, operations, and physicians.


Hospitals 1202.4

Permanent

MS-MED-60-12 Health RecordsMaster Patient Index

Master index to patient health records.

Permanent

MS-MED-60-14 Health RecordsRegister of Births

Register detailing all births occurring at the facility.

Permanent

MS-MED-60-16 Health RecordsRegister of Deaths

Register detailing all deaths occurring at the facility.

Permanent

MS-MED-60-18 Health RecordsRegister of Surgical Procedures

Register detailing all surgical procedures performed at the facility.

Permanent

MS-MED-60-19 Health RecordsPhysician On-Call Records

Includes lists of physicians, specialists and sub-specialists, on call for duty to stabilize individuals with emergency medical conditions.

42 USC1395(a)(1)(I)(iii)

5 years

MS-MED-60-20 Health RecordsEmergency Run Reports

Reports on patients revived, and/or attempted to be revived, by the administration of drugs, both inter-cardiac and intravenously, and by using counter-shock treatment. Includes all other patients who accepted service from an EMT, EMS or Air-Medical Provider, or a paramedic.

MS Code § 41-59-41

10 years

MS-MED-60-21 Health RecordsEmergency Room Logs

Records related to the emergency room.

Minimum Standards for Hospitals 701,

705.6

10 years

MS-MED-60-22 Health RecordsRecords of Sexually Transmitted Diseases 10 years



22 of 31


Total Retention

Records related to the identification and treatment of sexually transmitted diseases, which are not included in the patient’s medical record.

MS-MED-60-24 Health RecordsRecords of Tuberculosis

Records related to the identification and treatment of tuberculosis, including x-rays, which are not included in the patient’s medical record.

10 years

MS-MED-60-26 Health RecordsRecords of Hansen’s Disease

Records related to the identification and treatment of Hansen’s Disease, which are not included in the patient’s medical record.

10 years

MS-MED-60-28 Health RecordsCardiac Catherization Films

Films taken before, during, and after a heart catherization procedure.

5 years

MS-MED-60-30 Health RecordsImmunization Record and Consent Form

Signed consent forms and records noting the type of immunization performed which are not included in the patient’s medical record.

2 years

MS-MED-60-32 Health RecordsTumor Registry Files

Records related to the identification and treatment of tumors that are not included in the patient’s medical record.

MS Code § 41-91-5

75 Calendar years After Last

Entry

MS-MED-60-34 Health RecordsChild Abuse Reports

Records related the identification and treatment of child abuse victims.

MS Code § 41-9-69 (1)


to Exceed 28 years

MS-MED-60-36A Health RecordsDialysis Records-Adults

Records related to dialysis treatments.

MS Code § 41-9-69 (1)






23 of 31


Total Retention

MS-MED-60-36B Health RecordsDialysis Records-Minors

Records related to dialysis treatments.

MS Code § 41-9-69 (1)


to Exceed 28 years

MS-MED-60-38A Health RecordsAnesthesia Records-Adults

Records related to the administering of anesthesia.






MS-MED-60-38B Health RecordsAnesthesia Records-Minors

Records related to the administering of anesthesia.




to Exceed 28 years

MS-MED-60-40 Health RecordsAutopsy Records

Records related to autopsies.

MS Code § 41-37-13

7 years After Autopsy

MS-MED-70-02 Nursing RecordsStaffing Records

Daily, weekly, monthly, bimonthly work schedules, and assignment sheets for medical personnel. Includes nursing staff, medical aides, and support staff who provide medical treatment including phlebotomists.


Hospitals 801.2

CY+6 years

MS-MED-70-04 Nursing RecordsTraining Records

Records related to nurses training and certification.


Hospitals 806-807

ACT+3 years

MS-MED-70-06 Nursing RecordsVisit Notes

Records consist of observations and notes concerning patients, which are not included in the patient medical record.

CY+3 years



24 of 31


Total Retention

MS-MED-70-07 Nursing RecordsReference Cards

Includes duplicate copies of nursing reference notes.

AV

MS-MED-70-08 Nursing RecordsNursing Care Plans

Records related to daily care provided by nurses.


804.2

CY+6 years

MS-MED-70-10 Nursing RecordsNursing Care Manuals

Documentation manuals detailing nursing care procedures.


803.3

7 years After SUP

MS-MED-70-12 Nursing RecordsMinutes of Meetings

Notes or minutes from meeting, includes documented oral conversations and telephone calls pertaining to meeting notes/minutes.


Hospitals 804.3

CY+3 years; See ADM-90-09

MS-MED-80-02 Pharmacy RecordsControlled Substances – Inventory and Orders

Records related to the identification and treatment of required inventories and logs pertaining to drugs held by facilities, including pharmacists and EMS units. Includes narcotics.

MS Code § 41-29-133; Minimum

Standards for Hospitals 2002.1-

2002.3; Mississippi Pharmacy

Regulations XXIII.1; 21 CFR

1304.04 (a)

CY+2 years

MS-MED-80-03 Pharmacy RecordsAlcohol (Tax Free) Inventory 27 CFR 22.164 CY+ 3 years

From Date of Dispensing

MS-MED-80-04 Pharmacy RecordsControlled Substances – Dispensed and Administered

Records related to the dispensing and administering of controlled substances.

MS Code § 41-29-133; Minimum

Standards for Hospitals 2002.1, 2002.2, 2002.4;

CY+2 years



25 of 31


Total Retention

Mississippi Pharmacy

Regulations XXIII.1; 21 CFR

1304.04;21 CFR 1304.22

MS-MED-80-06 Pharmacy RecordsMethadone Records

Records related to the inventory and administration of methadone.

MS Code § 41-29-133; Minimum Standards for

Hospitals 2002.4; 21 CFR 310.505;21 CFR 291.505

(d)(13)(ii)

CY+3 years From Date of Dispensing

MS-MED-80-08 Pharmacy RecordsPrescriptions

Records related to written prescriptions maintained by pharmacies.


Hospitals 2002.4; 21 CFR

1304.04(h)

CY+2 years

MS-MED-80-10 Pharmacy RecordsPatient Profiles

Records related to patient profiles maintained by pharmacies. Includes records to whom new and/or refill prescriptions are dispensed.

CY+2 years

MS-MED-80-12 Pharmacy RecordsInspection Reports

Pharmacist inspection reports of emergency drug supplies.

MS Code § 73-21-107

CY+2 years

MS-MED-80-14 Pharmacy RecordsRecall Records Minimum

Standards for Hospitals 2005.4;

Mississippi Pharmacy

Regulations XXVI.1

CY+2 years

MS-MED-80-16 Pharmacy RecordsRadioactive Drugs Mississippi

Pharmacy CY+2 years



26 of 31


Total Retention

Includes inventory and orders of radioactive drugs. Regulations XXVII.4

MS-MED-80-18 Pharmacy RecordsPharmacy Register Mississippi

Pharmacy Regulations XVIII.3.6

CY+2 years

MS-MED-90-02 SafetyRisk Management Reports

Records related to internal risk management. Includes education and training for non-physician employees, analysis of patient grievances, review of incident reports, and minutes of the risk management committee.

CY+6 years

MS-MED-90-04 SafetyAir Sampling and Bioassays

Records related to the results of air sampling, bioassays, and surveys conducted in the radiology section which are sufficient enough to identify potential hazards, permit proper equipment selection, estimate exposure levels, and to evaluate actual intake levels.


License

MS-MED-90-06 SafetyIncident Reports

Reports of unusual incidents that are recorded by a witness to the incident in a formal manner such as a log, event book, incident form, etc. May be used to report security or injury incidents or to note disturbances in the work place such as fire alarms, roof leak, computer and power outages, car alarms, and other events.

CY+6 years After Incident

MS-MED-92-02 Waste DisposalBiomedical Waste Records

Records related to training, instruction, proper handling, and disposition of biomedical wastes.


Hospitals 1402.9 II.B.5

CY+3 years

MS-MED-92-04 Waste DisposalBiomedical Waste Shipment Logs

Records related to the shipment, weight, waste category, location points, and transporter’s receipt of biomedical waste.

CY+3 years

MS-MED-92-06 Waste DisposalBiomedical Waste – Exception Form CY+3 years



27 of 31


Total Retention

Records related to the tracking form for which there is no confirmation of delivery and a signed cover letter explaining the generator's efforts in locating the waste and the results of those efforts. The exception form is submitted to the EPA and appropriate state agency.

MS-MED-92-08 Waste Disposal On-site Incineration Records – Acceptance Records

Records documenting regulated medical waste to an on-site incinerator for disposal.

CY+3 years

MS-MED-92-10 Waste Disposal On-site Incineration Records – Operating Logs

Records related to the date, length, and total weight of medical waste incinerated per cycle.

CY+3 years

MS-MED-92-12 Waste DisposalRadioactive Waste Disposal Records

Records related to the disposal of radioactive waste and by-products. Includes date, method of disposal, name and address of the waste hauler, amount disposed of, and the name of the staff handling the disposal or transfer process.


License

MS-MED-92-14 Waste DisposalRadioactive Waste Disposal Records – Non-Sealed Source

Records related to the disposal of any radioactive material that is a non-sealed source with a physical half-life of less than 90 days.


License

MS-MED-94-02 Engineering RecordsEmergency Generator Records

Records related to the inspection, performance, maintenance, and repairs of emergency generators.

Life of Generator Plus 3

years

MS-MED-94-04 Engineering RecordsAir Filter Maintenance Records

Records related to the inspection, performance, and maintenance of air filters.

Life of Air Filter Plus 3 years

MS-MED-94-06 Engineering RecordsBlueprints and Construction Drawings MS Code § 41-9-

81; Minimum ACT+ 6 years;

See ADM-40-06



28 of 31


Total Retention

Blueprints and construction drawings detailing the design of company facilities.


MS-MED-94-08 Engineering RecordsConstruction Project Files

Work papers and reports related to specific construction projects.

ACT+10 years; See ADM-40-04

MS-MED-94-10 Engineering RecordsCalibration Records

Instrument calibration records performed in accordance with the manufacturer’s instructions.

CY+3 years; See MS-MED-

10-16

MS-MED-94-12 Engineering RecordsEquipment Operating Instructions

Records related to manufacturer’s operation instructions.

Life of Equipment Plus

3 yearsMS-MED-94-14 Engineering Records

Equipment Inspection and Maintenance Records

Records related to equipment inspections and required maintenance.


Hospitals 1401.4

CY+3 years; See MS-MED-

10-16

MS-MED-94-16 Engineering RecordsInspection Reports of Grounds and Buildings

Records related to the inspection reports of facility grounds and buildings.


Hospitals 1401.4

CY+3 years

MS-MED-94-18 Engineering RecordsWatchman Clock Dials 2 years

MS-MED-94-20 Engineering RecordsWork Orders

Work orders related to the inspection, maintenance, and repairs.

2 years

MS-MED-94-22 Engineering RecordsThermometer Charts CY+3 years

MS-MED-94-24 Engineering RecordsPermits/Licenses

Includes heliport, health permits, boiler permits, fire inspection permits, FCC license, etc.

MS Code § 41-9-81

Retain Until Expiration of

Permit or License Plus 6

years



29 of 31


Total Retention

MS-MED-94-26 Engineering RecordsOSHPD Project Permits and Inspection CY+5 years



30 of 31

Health & Medicine

Mississippi Medical/Facility Records Retention Schedule.doc.doc