| QUALITY
IMPROVEMENT |
|
|
Quality improvement outcome database, except peer review
|
permanent |
|
Quality improvement records -- peer review
|
7 years |
|
Medical staff records
|
75 years |
|
Impaired physician/clinician records
|
75 years |
|
HOUSESTAFF
|
|
|
Housestaff evaluations
|
7 years |
|
Other housestaff records
|
75 years |
|
REGULATORY RECORDS
|
|
|
Accreditation records
|
permanent |
|
Certificate of need (CON) records and determinations of non-reviewability
|
permanent |
|
Hospital service licensure records
|
permanent |
|
Surveys, deficiency citations and related plans of correction
|
permanent |
|
Records of waivers from standards
|
permanent |
|
Reports to licensing boards
|
permanent |
|
Risk and claims management records/incident reports/accident/loss
reports/expense records
|
7 years |
|
Health System policies and procedures
|
10 years after withdrawal/revision |
|
Reports of formal complaints, grievances, investigations
and dispositions
|
4 years |
|
MISCELLANEOUS
|
|
|
Pharmaceutical assistance contracts for the elderly
|
7 years |
|
Cost Reports/Claims under Medicare, Medicaid, or other third-party
payers
|
4 years from closing of cost report |
|
DIETARY SERVICE
|
|
|
Dietary service records
|
4 years |
|
NURSING SERVICE
|
|
|
Nursing patient assignment records
|
7 years |
|
Minutes of nursing administration staff meetings
|
5 years |
|
Nursing time/attendance schedules
|
7 years |
|
Nursing policies and clinical procedures
|
10 years |
|
PHARMACY SERVICE
|
|
|
Pharmacy records
|
7 years |
|
Records of serious, unexpected adverse drug experiences from
prescription drugs for human use without approved new drug applications
|
10 years |
|
LABORATORY, PATHOLOGY AND BLOOD
SERVICES
|
|
|
Laboratory records, unless otherwise specified
|
4 years |
|
Clinical laboratory permit
|
permanent |
|
Immunohematology and tranfusion test and reports
|
5 years |
|
Blood and blood quality control and testing records
|
later of 5 years after processing records
are completed or 6 months after expiration; permanent if no expiration |
|
Policies to insure positive identification of a blood or
blood product recipient
|
10 years |
|
Certification of good health of donors for manufacture of
Plasma Cryoprecipitated AHF or Source Plasma
|
7 years |
|
Complaints of adverse reactions regarding each unit of blood
or blood production arising as a result of blood collection
or transfusion
|
7 years |
|
Written report of investigations of each reported adverse
blood collection or transfusion reaction
|
7 years |
|
Blood bank compatibility records
|
7 years |
|
Records or remedial actions taken to prevent future recurrences
or transfusion reactions
|
7 years |
|
Copy of blood donor registry sent to blood bank by PA Dept.
of Health
|
most recent |
|
Written procedures for collection, processing, compatibility
testing, storage and distribution of blood and blood components
for homologous transfusion, autologous transfusion and further
manufacturing purposes
|
10 years |
|
Manual of standard operating procedures and methods for blood
collecting and transfusion
|
10 years |
|
Manufacturing records of biological products licensed by
Secretary of HHS
|
later of 5 years after records of manufacture
completed or 6 months after the latest expiration date for individual
product |
|
Record of name and qualifications of person immediately in
charge of employees who determine suitability of donors or collect
blood when a physician is not present on the premises
|
7 years |
|
Records related to blood collection, processing, compatibility
testing, storage and distribution
|
later of 5 years after the records
of processing have been completed or 6 months after the latest
expiration date for the individual product. When there is no expiration
date, records shall be retained indefinitely |
|
Cytology slide preparations not loaned to proficiency testing
programs
|
permanent |
|
Pathology test reports
|
permanent |
|
Written procedures for reporting imminent life-threatening
laboratory results or panic values
|
permanent |
|
Records of laboratory/pathology equipment maintenance and
function checks
|
life of equipment |
|
Premalignant and malignant section slide preparations
|
permanent |
|
Histopathology stained slides
|
permanent |
|
Histocompatibility records
|
permanent |
|
Autopsy records
|
permanent |
|
Clinical, surgical, pathology and cytology records
|
permanent |
|
RADIOLOGY AND NUCLEAR MEDICINE
SERVICES
|
|
|
Radiology records of current inspections by radiation health
specialists
|
4 years |
|
Mammogram records
|
10 years |
|
Radiology records, films, scans and other image records
|
7 years |
|
Nuclear medicine; radioisotope records
|
permanent or until authorized by Nuclear
Regulatory Commission for disposal |
|
Nuclear medicine instrument log books
|
life of instrument |
|
Nuclear medicine annual accumulation records on personnel
|
becomes part of personnel file |
|
Nuclear medicine patient records (department duplicate of
medical record)
|
4 years |
|
Copies of reports of nuclear medicine interpretations, consultations,
and procedures and disposition of pharmaceuticals
|
7 years |
|
REHABILITATION SERVICE RECORDS,
EXCEPT QUALITY IMPROVEMENT
|
4 years
|
|
SPECIAL CARE UNIT
|
|
|
Special care unit records, except quality improvement
|
4 years |
|
EMERGENCY SERVICE
|
|
|
Emergency service records and logs, except quality improvement
|
7 years |
|
Emergency patient care policies and procedures
|
10 years |