Policies for

Retention and
Destruction of
Health Records at
ABC Hospital-2017
Version
Written by: Cassidy DeVore

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 Table of Contents:

Page 3: Retention of the Health Record

Page 4: Destruction of Health Records
Page 5: Policy Pledge for ABC Hospital
Page 6: References

Retention of the Health Record:

The following health care documentation must undergo a retention period:

Register of birth.

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 Register of death.
Surgical Procedures.
Master Patient Index.
Physician index.
Diagnostic images.
Disease index.

The retention period is the number of years a health care document will be kept in the
hospital or electronic health record system.
The retention period will last up to 5 to 10 years depending on the type of health care
documentation. The following documentations will go through this retention period:
Diagnostic imaging: 5 years.
Patient medical records: 10 years after most recent visit.
Operative index: 10 years.
Physician index: 10 years.
Disease index: 10 years.

Some health records will be held into the EHR system or be kept paper-based in the
hospital permanently. The following health care documents will be kept in the hospital
system permanently:
Register of birth.
Register of death.
Record of surgical procedures.
Master patient index.

Destruction of Health Records:

Since ABC hospital is transitioning to an electronic health record system in

June 2017, it is important to know how to destroy paper based
documentation. Destroying paper based documentation will help not reveal
any patient information that is to be kept confidential.

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 The following are acceptable methods of destroying these types of documentation:
Burning (Paper documentation)
Incineration (Paper documentation)
Shredding (CDs and optical disks)
Pulverizing (CDs, optical disks, paper documentation, and micrographic film).
Degaussing (only with magnetic tapes and electronic records).
Recycling (Micrographic film)

When destroying health records, there are elements that need to be stated in a certificate
of destruction. The certificate of destruction shows documentation of how the health
record was destroyed.
The following must be documented on the certificate of destruction:
Date the document was destroyed.
The method used when the document was destroyed.
The hospital where the document was destroyed.
Signature(s) of the witnesses of the destruction of the document.
Date and time of the signature(s).

The following is NOT an acceptable method of destruction to documents:

Throwing it in the trash.

***This method is not acceptable because somebody could stumble upon it and it could
go into the wrong hands. If any documents are found in the trash, the person who was
accountable for the documentation that day will be sent to an orientation on how to
properly destroy documentation and will be prohibited from coming into the facility for
48 hours. This is such an important rule when dealing with health records of other
patients, so the consequences will be harsh. If you have any questions about the
destruction of health records, please refer to this page of the policy manual. ***

Policy Pledge of ABC Hospital:

I, the hospital employee of the Medical Records Department solemnly swear to follow all
procedures, policies, and protocols that this policy manual describes. I understand that I
am held accountable for my actions and consequences will be served if I disobey these
policies. I understand that these policies were established for the safety and protection of
the patient and the hospital facility. I have read the entire policy manual and hereby sign

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this policy pledge to show my understanding and commitment to the ABC Hospital
policies, procedures, and protocols.

Signature: Date:

Please sign this policy pledge and returned to Cassidy DeVore, Director of Medical
Records at ABC Hospital. The pledge will be kept on file for accountability purposes. We
are looking forward to the implentation of the new EHR system coming in June 2017!

References:

Fahrenholz, C. & Russo, R. (2013). Documentation for health records. Chicago, IL:
American Health Information Management Association.