florida medical/facility records retention schedule

HCA Record Retention Schedule - Medical/Facility Records

State of Florida

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 Duplicates should be retained until obsolete, superseded, or administrative value is lost.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

FL-MED-10-01 Administrative OfficesAnnual Reports to State Departments of Health Permanent

FL-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.

GS-4ITEM 6

Permanent

FL-MED-10-04 Administrative OfficesDaily Census

Daily patient census data.

CY+5 years

NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health Care Facilities and Medical ProvidersLEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value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: August 15, 2000Revised: September 10, 2003

1 of 30


Total Retention

FL-MED-10-05 Administrative OfficesHospital Permits

Required permits to operate a hospital.

Retain Until Suspended or

Revoked

FL-MED-10-06 Administrative OfficesCommunicable Disease Reports

Reports related to communicable diseases.

CY+3 years

FL-MED-10-07 Administrative OfficesMedical Staff Files

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

Life of Hospital

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

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

Life of Hospital

FL-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.

Life of Hospital

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

Copies of death records required by local government.

GS-4ITEM 22

Permanent

FL-MED-10-11 Administrative OfficesDeath Records

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

CY+3 years

FL-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.

GS-4ITEM 2; 42 USC 1395cc(a)(1)(I)

(ii)

CY+6 years



2 of 30


Total Retention

FL-MED-10-14 Administrative OfficesAdmissions/Discharges Register

Official register of all patient admissions and discharges.

CY+6 years

FL-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

FL-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.

GS-4ITEM 1

5 years After Next

Accreditation is Issued

FL-MED-10-22 Administrative OfficesMedical Directives, Policies and Procedures

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

GS-4ITEM 120

7 years After SUP

FL-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

FL-MED-10-25 Administrative OfficesEmployee Training

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

2 years

FL-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



3 of 30


Total Retention

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

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

CY+3 years

FL-MED-10-29 Administrative OfficePatient Personal Property Inventory 3 years After

DischargeFL-MED-10-30 Administrative Offices

Inspection Reports

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

10 CFR 30.51 CY+5 years

FL-MED-10-32 Administrative OfficesOSHA Records

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

29 CFR 1904.6 CY+5 years

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

FL-MED-12-02 Housekeeping RecordsAutoclave Records 2 years

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

FL-MED-12-06 Housekeeping RecordsCleaning Records 2 years

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

FL-MED-12-10 Housekeeping RecordsExterminator Records 2 years

FL-MED-30-02 Dietary RecordsFood Costs

Records related to food and food service costs.

CY+5 years



4 of 30


Total Retention

FL-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 food service.

GS-4ITEM 54

CY+2 years

FL-MED-30-05 Dietary RecordsInspection Reports Retain 1 year

After SUP

FL-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.

GS-4ITEM 28

AV

FL-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.

GS-4ITEM 111

2 years

FL-MED-30-10 Dietary RecordsInservice Training Records ACT +3

yearsFL-MED-30-12 Dietary Records

Bacteriological Testing of Ice 2 years

FL-MED-30-14 Dietary RecordsMeal Counts 2 years

FL-MED-40-02 Clinic RecordsAppointment Books

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

CY+3 years

FL-MED-40-04 Clinic RecordsEncounter Statistics

Statistical data for clinic encounters.

CY+5 years



5 of 30


Total Retention

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

Clinic patients social service case histories.

GS-4ITEMS 80

Adults 7 years After Last Entry

FL-MED-40-06B Clinic RecordsSocial Service Confidential Case Histories-Minors

Clinic patients social service case histories.

Minors Age of Majority Plus 7 years

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

Clinic records related to welfare agencies.

GS-4ITEMS 80


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

Clinic records related to welfare agencies.


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

Records related to adverse reactions to blood transfusions.

GS-4ITEM 121; 21 CFR 606.160

5 years

FL-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.

GS-4ITEM 122; 21 CFR 606.160

5 years After Processing or

6 Months After the

Latest Expiration

DateIf There is No

Expiration Date, Records are Retained Permanently



6 of 30


Total Retention

FL-MED-50-04 Laboratory, Therapy, and Imaging 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.

GS-4ITEM 122; 21 CFR 606.160


6 Months After the

Latest Expiration

DateIf There is No


FL-MED-50-06 Laboratory, Therapy, and ImagingBlood Bank – ABO and RH Types

Records related to type testing of blood.

GS-4ITEM 121; 21 CFR 606.160

5 years

FL-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.

GS-4ITEM 122; 21 CFR 606.160

5 years After

Processing or 6 Months After the

Latest Expiration

DateIf There is No


FL-MED-50-08 Laboratory, Therapy, and ImagingBlood Bank – Blood Test Results

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

GS-4ITEM 121; 21 CFR 606.160

5 years

FL-MED-50-10 Laboratory, Therapy, and Imaging Blood Bank - Final Disposition of Blood and Components

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

GS-4ITEM 121; 21 CFR 606.160

5 years



7 of 30


Total Retention

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

Records detailing blood inspection and refrigeration.

GS-4ITEM 122; 21 CFR 606.160


6 Months After the

Latest Expiration

DateIf There is No


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

Transfusion requests received by the blood bank.

GS-4ITEM 122; 21 CFR 606.160


6 Months After the

Latest Expiration

DateIf There is No


FL-MED-50-15 Laboratory, Therapy, and ImagingEchocardiogram Tracings

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.

GS-4ITEM 118

30 Days After Report is Filed, If a

Report is not Filed, Strips

have the Same

Retention as the Patient

Medical File



8 of 30


Total Retention

FL-MED-50-16 Laboratory, Therapy, and ImagingElectrocardiogram Tracings

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.

GS-4ITEM 118

30 Days After Report is Filed If a


have the Same


Medical File

FL-MED-50-18 Laboratory, Therapy, and ImagingElectroencephalogram Tracings

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.

GS-4ITEM 118



have the Same


Medical File

FL-MED-50-19 Laboratory, Therapy, and ImagingElectromyogram Tracings

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



have the Same


Medical FileFL-MED-50-20 Laboratory, Therapy, and Imaging

Radioisotopes

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

10 CFR 30.51 5 years



9 of 30


Total Retention

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

Requisitions authorizing a laboratory to perform tests on a sample.

GS-4ITEM 95; 42

CFR 493.1105

2 years

FL-MED-50-22 Laboratory, Therapy, and ImagingTherapy Treatment Records

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

10 years

FL-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.

GS-4ITEM 85; 42

CFR 493.1109

10 years After Date of

Reporting

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

Records related to autoclave/sterile supply.

2 years

FL-MED-50-25 Laboratory, Therapy, and ImagingSterilizers/Monthly Bacteriological Tests

Records related to sterilizers and monthly bacteriological tests.

3 years

FL-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.

GS-4ITEM 84; 42

CFR 493.1109

5 years

FL-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



10 of 30


Total Retention

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

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

GS-4ITEM 83; 42

CFR 493.1101

2 years

FL-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.

GS-4ITEM 99

Permanent

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

493.1259 (b)Wet Tissue 7

days After Sign Out

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

493.1259 (b)2 years

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

42 CFR 493.1257(g);

5 years

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

493.1259 (b)10 years

FL-MED-50-34 Laboratory, Therapy, and ImagingSpecimen Logs

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.

10 years

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

Records related to the testing of bone marrow.

GS-4ITEMS 80


FL-MED-50-35B Laboratory, Therapy, and Imaging

Bone Marrow Test Reports-Minors

Records related to the testing of bone marrow.




11 of 30


Total Retention

FL-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

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

Includes oral, written, and electronic requests for tests.

42 CFR 493.1105

2 years

FL-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.

GS-4ITEM 103

4 years After Procedure is Discontinued

FL-MED-50-39 Laboratory, Therapy, and ImagingTest Procedures - Errors

Records include original and corrected reports.

42 CFR 493.1219(d)(3)

2 years

FL-MED-50-40 Laboratory, Therapy, and ImagingEchocardiogram Video Tapes

Videotapes created during an echocardiogram.

5 years

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

Videotapes created for other diagnostic tests not listed elsewhere.

5 years

FL-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.

GS-4ITEMS 80




12 of 30


Total Retention

FL-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.


FL-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

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

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

GS-4ITEMS 80


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

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


FL-MED-50-48A Laboratory, Therapy, and ImagingScreenings for Infant Genetic or Metabolic Disorders-Copies

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

Copies CY+7 years

FL-MED-50-48B Laboratory, Therapy, and ImagingScreenings for Infant Genetic or Metabolic Disorders-Originals

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

Originals Age of Majority Plus 7 years

FL-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.

GS-4ITEM 117

2 years



13 of 30


Total Retention

FL-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.

GS-4ITEM 94; 42 CFR 493.903

5 years

FL-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.

GS-4ITEM 87

2 years

FL-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.

GS-4ITEM 105

3 years

FL-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.

GS-4ITEM 105

3 years

FL-MED-50-58 Laboratory, Therapy, and Imaging 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.

GS-4ITEM 115

2 years

FL-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.

GS-4ITEM 101

2 years After Compliance



14 of 30


Total Retention

FL-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.

GS-4ITEM 114

3 years

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

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

GS-4ITEM 108

3 years

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

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

GS-4ITEM 124

1 year After Termination or Expiration

of License

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

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

5 years

FL-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.

GS-4ITEM 100

7 years After Separation or Termination

of Employment

FL-MED-50-70 Laboratory, Therapy, and ImagingPlanned Special Exposure

Records documenting planned and authorized radiological exposure.

GS-4ITEM 112


of License

FL-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.

GS-4ITEM 123


of License



15 of 30


Total Retention

FL-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.

GS-4ITEM 88


of License

FL-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.

GS-4ITEM 86

3 years

FL-MED-50-78 Laboratory, Therapy, and Imaging Radiation 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.

GS-4ITEM 104

3 years

FL-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.

GS-4ITEM 106

3 years

FL-MED-50-81 Laboratory, Therapy, and ImagingNuclear Medicine Reports

Includes nuclear medicine interpretations, consultations, and procedures.

10 years

FL-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



16 of 30


Total Retention

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

Records of the calibrations of the therapy system.

2 years

FL-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.

2 years

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

Original mammograms.

10 years

FL-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 FL-MED-60-06.

GS-4ITEM 90

10 years

FL-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

FL-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.

GS-4ITEM 91

7 years After Investigation

FL-MED-50-96 Laboratory, Therapy, and Imaging Mammography – Quality Control Surveys

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

GS-4ITEM 92

1 calendar year



17 of 30


Total Retention

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

Administrative records for individual facility records.

CY+3 years

FL-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 FL-MED-80-02.

2 years

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

Log books for individual facility departments not listed elsewhere.

CY+3 years

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

Quality control reports for individual facility departments.

5 years

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

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

GS-4ITEM 120

7 years After SUP

FL-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.

GS-4ITEM 74

CY+5 years

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

Records related to Respiratory Protection Programs.

GS-4ITEM 107


of License



18 of 30


Total Retention

FL-MED-55-14 Facility/Department RecordsTraining and Education Records

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

ACT+3 years

FL-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.

GS-4ITEM 82; 42

CFR 493.1221; 21 CFR 606.160

5 years

FL-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.

GS-4ITEM 81; 42

CFR 493.1221(a)

2 years

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

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

1 year

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

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

10 years

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

Implant logs listing items implanted into patients during surgical procedures.

10 years

FL-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.

GS-4ITEM 23

10 years



19 of 30


Total Retention

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

Schedules of procedures performed in an operating room.

3 years

FL-MED-55-30 Facility/Department RecordsX-Ray Logs

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

GS-4ITEM 98

10 years

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

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

2 years

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

Records detailing the proceedings of the Air Ambulance Safety Committee.

GS-4ITEM 125

2 years

FL-MED-55-38 Facility/Department RecordsSpecial Procedures Unit

Records related to endoscopies, and other outpatient surgeries. Include patient arrival and departure times and is documented in the patient’s medical file.

CY+ 3 years

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

Published papers from medical staff.

Permanent

FL-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



20 of 30


Total Retention

FL-MED-58-06 Medical Research RecordsResearch Reports

Reports related to medical research.

10 years

FL-MED-60-01 Health RecordsPatient Medical Records – Nursing Home Minors

Complete health records for patients seeking care or service from a nursing home provider.

GS-4ITEM 133

Retain Until 24 years of Age or 7

years After Last Entry,

Whichever is Longer

FL-MED-60-02 Health RecordsPatient Medical Records – Adults

Complete health records for adult patients.

GS-4ITEM 80

7 years After Last Entry

FL-MED-60-03 Health RecordsPatient Medical Records – Children Under One Year Of Age

Complete health records for children under one year of age.


FL-MED-60-04 Health RecordsPatient Medical Records – Minors Over One Year of Age

Complete health records for minors.

GS-4ITEM 80


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

Psychiatric evaluations and treatment provided to patients.

GS-4ITEM 80


FL-MED-60-05B Health Records

Psychiatric Records-Minors

Psychiatric evaluations and treatment provided to patients.




21 of 30


Total Retention

FL-MED-60-06A 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.

GS-4ITEM 78

7 years

FL-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

FL-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.

GS-4ITEM 130


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

Health records indexes for disease, operations, and physicians.

GS-4ITEM 60

Permanent

FL-MED-60-12 Health RecordsMaster Patient Index

Master index to patient health records.

GS-4ITEM 49

Permanent

FL-MED-60-14 Health RecordsRegister of Births

Register detailing all births including still births occurring at the facility.

Permanent

FL-MED-60-16 Health RecordsRegister of Deaths

Register detailing all deaths occurring at the facility.

Permanent

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

Register detailing all surgical procedures performed at the facility.

Permanent



22 of 30


Total Retention

FL-MED-60-19 Health RecordsPhysicians On-Call Records

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

42 USC 1395(a)(1)(I)(iii)

5 years

FL-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.

GS-4ITEM 70

10 years

FL-MED-60-21 Health RecordsEmergency Room Logs

Records related to the emergency room.

10 years

FL-MED-60-22 Health RecordsRecords of Sexually Transmitted Diseases

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

7 years

FL-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.

7 years

FL-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.

7 years

FL-MED-60-28 Health RecordsCardiac Catherization Films

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

7 years

FL-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



23 of 30


Total Retention

FL-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.

GS-4ITEM 10

75 Calendar years After Last Entry

FL-MED-60-34 Health RecordsChild Abuse Reports

Records related the identification and treatment of child abuse victims.

GS-4ITEMS 130


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

Records related to dialysis treatments.

GS-4ITEMS 80



Dialysis Records-Minors

Records related to dialysis treatments.


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

Records related to the administering of anesthesia.

GS-4ITEMS 80



Anesthesia Records-Minors

Records related to the administering of anesthesia.


FL-MED-60-40 Health RecordsAutopsy Records

Records related to autopsies.

7 years After Autopsy

FL-MED-70-02 Nursing RecordsStaffing Records

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

GS-4ITEM 126

7 years



24 of 30


Total Retention

FL-MED-70-04 Nursing RecordsTraining Records

Records related to nurses training and certification.

ACT+3 years

FL-MED-70-06 Nursing RecordsVisit Notes

Records consist of observations and notes concerning patients, which do not become part of the patient medical record.

CY+3 years

FL-MED-70-07 Nursing RecordsReference Cards

Includes duplicate copies of nursing reference notes.

AV

FL-MED-70-08 Nursing RecordsNursing Care Plans

Records related to daily care provided by nurses.

GS-4ITEM 126

7 years

FL-MED-70-10 Nursing RecordsNursing Care Plans Manuals

Documentation manuals detailing nursing care procedures.

GS-4ITEM 120

7 years After SUP

FL-MED-70-12 Nursing RecordsMinutes of Meetings

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

CY+3 years; See ADM-

90-09

FL-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 alcohol inventory.

GS-4ITEM 127; 21

CFR 1304.04(a)

CY+2 years

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

From Date of Transaction



25 of 30


Total Retention

FL-MED-80-04 Pharmacy RecordsControlled Substances - Dispensed and Administered

Records related to the dispensing and administering of controlled substances.

GS-4ITEM 127; 21 CFR 1304.04

CY+2 years From Date of Dispensing

FL-MED-80-06 Pharmacy RecordsMethadone Records

Records related to the inventory and administration of methadone.

GS-4ITEM 127; 21

CFR 310.505; 21 CFR 291.505(d)

(13)(ii)

CY+3 years From Date of Dispensing

FL-MED-80-08 Pharmacy RecordsPrescriptions

Records related to written prescriptions maintained by pharmacies.

GS-4ITEM 64; 21

CFR 1304.4(h)

CY+2 years

FL-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.

GS-4ITEM 129

CY+ 3 years

FL-MED-80-12 Pharmacy RecordsInspection Reports

Pharmacist inspection reports of emergency drug supplies.

CY+2 years

FL-MED-80-14 Pharmacy RecordsRecall Records CY+2 years

FL-MED-80-16 Pharmacy RecordsRadioactive Drugs

Includes inventory and orders of radioactive drugs.

CY+2 years

FL-MED-80-18 Pharmacy RecordsPharmacy Register CY+3 years

From Date of Dispensing



26 of 30


Total Retention

FL-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.

GS-4ITEM 69

CY+6 calendar

years

FL-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.

GS-4ITEM 107


of License

FL-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.

GS-4ITEM 40

7 calendar years After

Incident

FL-MED-92-02 Waste DisposalBiomedical Waste Records

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

GS-4ITEM 96

CY+3 years

FL-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.

GS-4ITEM 96

CY+3 years



27 of 30


Total Retention

FL-MED-92-06 Waste DisposalBiomedical Waste - Exception Form

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.

GS-4ITEM 96

CY+3 years

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

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

GS-4ITEM 97

CY+3 years

FL-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.

GS-4ITEM 97

CY+3 years

FL-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.

GS-4ITEM 89


of License

FL-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.

GS-4ITEM 113

CY+3 years

FL-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

FL-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



28 of 30


Total Retention

FL-MED-94-06 Engineering RecordsBlueprints and Construction Drawings

Blueprints and construction drawings detailing the design of company facilities.

ACT+ 6 years; See

ADM-40-06

FL-MED-94-08 Engineering RecordsConstruction Project Files

Work papers and reports related to specific construction projects.

ACT+10 years; See

ADM-40-04

FL-MED-94-10 Engineering RecordsCalibration Records

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

CY+3 years See FL-

MED-10-16

FL-MED-94-12 Engineering RecordsEquipment Operating Instructions

Records related to manufacturer’s operation instructions.

Life of Equipment Plus 3 years

FL-MED-94-14 Engineering RecordsEquipment Inspection and Maintenance Records

Records related to equipment inspections and required maintenance.

CY+3 years; See FL-

MED-10-16

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

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

CY+3 years

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

FL-MED-94-20 Engineering RecordsWork Orders

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

2 years

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



29 of 30


Total Retention

FL-MED-94-24 Engineering RecordsPermits/Licenses

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

Retain Until Expiration of

Permit or License Plus

3 yearsFL-MED-94-26 Engineering Records

OSHPD Project Permits and Inspection CY+5 years



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florida medical/facility records retention schedule

Documents