HCA                                     Record Retention Schedule - Medical/Facility Records                              ...
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Florida Medical/Facility Records Retention Schedule
Florida Medical/Facility Records Retention Schedule
Florida Medical/Facility Records Retention Schedule
Florida Medical/Facility Records Retention Schedule
Florida Medical/Facility Records Retention Schedule
Florida Medical/Facility Records Retention Schedule
Florida Medical/Facility Records Retention Schedule
Florida Medical/Facility Records Retention Schedule
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Florida Medical/Facility Records Retention Schedule

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Florida Medical/Facility Records Retention Schedule

  1. 1. HCA Record Retention Schedule - Medical/Facility Records State of FloridaFor 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 Duplicates should be retained until obsolete, superseded, oradministrative value is lost. The official record copy may be in hardcopy, electronic, and/or microform format. If the hardcopy isthe original record and is scanned into an imaging system, the hardcopy should be retained for the duration of the retention untilfurther notice.Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-10-01 Administrative Offices Annual Reports to State Departments of Health PermanentFL-MED-10-02 Administrative Offices Birth Records to Local Government GS-4 Permanent ITEM 6 Records consist of copies of vital birth records and certificates filed with state registrar of vital statistics.FL-MED-10-04 Administrative Offices Daily Census CY+5 years Daily patient census data.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 1 of 30
  2. 2. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-10-05 Administrative Offices Hospital Permits Retain Until Suspended or Required permits to operate a hospital. RevokedFL-MED-10-06 Administrative Offices Communicable Disease Reports CY+3 years Reports related to communicable diseases.FL-MED-10-07 Administrative Offices Medical Staff Files Life of Hospital Medical staff files including certification, credentials, complaints and continuing education records.FL-MED-10-08 Administrative Offices Constitution and Medical Staff Bylaws Life of Hospital Records documenting the terms, conditions, and procedures by which the facility will operate.FL-MED-10-09 Administrative Offices Minutes of Board of Directors, Executive Committee, Medical Staff Life of Hospital Records detailing the proceedings of board of directors, executive committee, and medical staff meetings. For department, committee, or project meetings use ADM-90-09.FL-MED-10-10 Administrative Offices Death Records to Local Government GS-4 Permanent ITEM 22 Copies of death records required by local government.FL-MED-10-11 Administrative Offices Death Records CY+3 years Records that track the transfer of corpses from the hospital to outside locations.FL-MED-10-12 Administrative Offices Statistics on Admissions, Services, and Discharges GS-4 CY+6 years ITEM 2; 42 USC Statistical data compiled into various reports detailing patient admissions, 1395cc(a)(1)(I) services rendered, transfers, leave of absences, and discharges. (ii)NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 2 of 30
  3. 3. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-10-14 Administrative Offices Admissions/Discharges Register CY+6 years Official register of all patient admissions and discharges.FL-MED-10-16 Administrative Offices Medical Equipment Logs CY+3 years 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.FL-MED-10-20 Administrative Offices Accreditation Surveys and Reports GS-4 5 years After ITEM 1 Next Records related to accreditation surveys and results. Includes inspection Accreditation reports by accrediting institutions, notices of corrections, correction reports, is Issued activity calendars, in-house surveys, and testing done prior to the actual accreditation survey.FL-MED-10-22 Administrative Offices Medical Directives, Policies and Procedures GS-4 7 years After ITEM 120 SUP Directives, policies, and procedures for facility operations. Includes emergency code procedures and cards.FL-MED-10-24 Administrative Offices Training Programs ACT+3 years Records related to classes and training programs provided to patients and customers by clinical staff. Includes Lamaze, CPR, and first aid.FL-MED-10-25 Administrative Offices Employee Training 2 years Records related to employee training provided on hazards and use of pesticides.FL-MED-10-26 Administrative Offices Volunteer Records 2 years After Termination Records related to work activities of volunteers at facilities. Includes work schedules, location, and duties performed.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 3 of 30
  4. 4. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-10-28 Administrative Offices Deceased Patients Property Disposition CY+3 years Records relating to the disposition of deceased patient’s personal property.FL-MED-10-29 Administrative Office Patient Personal Property Inventory 3 years After DischargeFL-MED-10-30 Administrative Offices Inspection Reports 10 CFR 30.51 CY+5 years Reports of inspection by local, state, or federal agents.FL-MED-10-32 Administrative Offices OSHA Records 29 CFR 1904.6 CY+5 years Records include logs, summaries, and OSHA forms 102/102a.FL-MED-10-34 Administrative Offices Pastoral Visitation Log CY+3 yearsFL-MED-12-02 Housekeeping Records Autoclave Records 2 yearsFL-MED-12-04 Housekeeping Records Checkout, Transfer, Isolation Records 2 yearsFL-MED-12-06 Housekeeping Records Cleaning Records 2 yearsFL-MED-12-08 Housekeeping Records Linen Poundage Report 2 yearsFL-MED-12-10 Housekeeping Records Exterminator Records 2 yearsFL-MED-30-02 Dietary Records Food Costs CY+5 years Records related to food and food service costs.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 4 of 30
  5. 5. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-30-04 Dietary Records Menus GS-4 CY+2 years ITEM 54 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.FL-MED-30-05 Dietary Records Inspection Reports Retain 1 year After SUPFL-MED-30-06 Dietary Records Dietary Recipe Records GS-4 AV ITEM 28 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.FL-MED-30-08 Dietary Records Dietician Counseling Summaries GS-4 2 years ITEM 111 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.FL-MED-30-10 Dietary Records Inservice Training Records ACT +3 yearsFL-MED-30-12 Dietary Records Bacteriological Testing of Ice 2 yearsFL-MED-30-14 Dietary Records Meal Counts 2 yearsFL-MED-40-02 Clinic Records Appointment Books CY+3 years Patient appointment books that record the appointment time and patient name.FL-MED-40-04 Clinic Records Encounter Statistics CY+5 years Statistical data for clinic encounters.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 5 of 30
  6. 6. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-40-06A Clinic Records Social Service Confidential Case Histories-Adults GS-4 Adults 7 ITEMS 80 years After Clinic patients social service case histories. Last EntryFL-MED-40-06B Clinic Records Social Service Confidential Case Histories-Minors Minors Age of Majority Clinic patients social service case histories. Plus 7 yearsFL-MED-40-08A Clinic Records Welfare Agency Records-Adults GS-4 Adults 7 ITEMS 80 years After Clinic records related to welfare agencies. Last EntryFL-MED-40-08B Clinic Records Welfare Agency Records-Minors Minors Age of Majority Clinic records related to welfare agencies. Plus 7 years FL-MED-50-02 Laboratory, Therapy, and Imaging Blood Bank – Adverse Reactions to Transfusions GS-4 5 years ITEM 121; 21 Records related to adverse reactions to blood transfusions. CFR 606.160 FL-MED-50-03 Laboratory, Therapy, and Imaging Blood Bank – General Records GS-4 5 years After ITEM 122; 21 Processing or Records related to information concerning sterilization of supplies and CFR 606.160 6 Months reagents, responsible personnel, errors and accidents, maintenance of After the equipment and the physical plant, expiration dates of supplies and reagents, Latest and logs which indicate on-hand inventory and notices of emergency Expiration shortages. Date If There is No Expiration Date, Records are Retained PermanentlyNOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 6 of 30
  7. 7. Record Series TotalCode Record Series Title & Description Legal Citation Retention FL-MED-50-04 Laboratory, Therapy, and Imaging Blood Bank – Blood Donor Records GS-4 5 years After ITEM 122; 21 Processing or Records related to blood donors including histories, examinations, consent, CFR 606.160 6 Months reactions, donor selection, results of required tests performed on After the plasmpheresis and cytopheresis donors, permanent and temporary deferrals, Latest investigation and follow-up, therapeutic bleedings, immunization, and blood Expiration collection. Date If There is No Expiration Date, Records are Retained Permanently FL-MED-50-06 Laboratory, Therapy, and Imaging Blood Bank – ABO and RH Types GS-4 5 years ITEM 121; 21 Records related to type testing of blood. CFR 606.160 FL-MED-50-07 Laboratory, Therapy, and Imaging Blood Bank - Quality Control GS-4 5 years ITEM 122; 21 After Records related to the calibration and standardization of equipment, CFR 606.160 Processing or performance checks, periodic check of sterile technique, and periodic tests of 6 Months the capacity of shipping containers to maintain the proper temperature. After the Latest Expiration Date If There is No Expiration Date, Records are Retained PermanentlyFL-MED-50-08 Laboratory, Therapy, and Imaging Blood Bank – Blood Test Results GS-4 5 years ITEM 121; 21 Records related to blood test results including interpretations and release data CFR 606.160 for compatibility testing. FL-MED-50-10 Laboratory, Therapy, and Imaging Blood Bank - Final Disposition of Blood and Components GS-4 5 years ITEM 121; 21 Records related to the final disposition of blood and blood components. CFR 606.160NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 7 of 30
  8. 8. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-50-12 Laboratory, Therapy, and Imaging Blood Bank - Refrigeration and Blood Inspection Records GS-4 5 years After ITEM 122; 21 Processing or Records detailing blood inspection and refrigeration. CFR 606.160 6 Months After the Latest Expiration Date If There is No Expiration Date, Records are Retained PermanentlyFL-MED-50-14 Laboratory, Therapy, and Imaging Blood Bank – Transfusion Request Records GS-4 5 years After ITEM 122; 21 Processing or Transfusion requests received by the blood bank. CFR 606.160 6 Months After the Latest Expiration Date If There is No Expiration Date, Records are Retained Permanently FL-MED-50-15 Laboratory, Therapy, and Imaging Echocardiogram Tracings GS-4 30 Days After ITEM 118 Report is Patient echocardiogram tracing. Includes actual strips generated by Filed, If a echocardiogram monitors and testing devices where a report or interpretation Report is not has been recorded in the patient medical record. Filed, Strips have the Same Retention as the Patient Medical FileNOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 8 of 30
  9. 9. Record Series TotalCode Record Series Title & Description Legal Citation Retention FL-MED-50-16 Laboratory, Therapy, and Imaging Electrocardiogram Tracings GS-4 30 Days After ITEM 118 Report is Patient electrocardiogram tracings. Includes actual strips generated by Filed If a electrocardiogram monitors and testing devices where a report or Report is not interpretation has been recorded in the patient medical record. Filed, Strips have the Same Retention as the Patient Medical FileFL-MED-50-18 Laboratory, Therapy, and Imaging Electroencephalogram Tracings GS-4 30 Days After ITEM 118 Report is Patient electroencephalogram tracings. Includes actual strips generated by Filed, If a electroencephalogram monitors and testing devices where a report or Report is not interpretation has been recorded in the patient medical record. Filed, Strips have the Same Retention as the Patient Medical FileFL-MED-50-19 Laboratory, Therapy, and Imaging 30 Days After Electromyogram Tracings Report is Filed, If a Patient electromyogram tracings. Includes actual strips generated by Report is not electroencephalogram monitors and testing devices where a report or Filed, Strips interpretation has been recorded in the patient medical record. have the Same Retention as the Patient Medical FileFL-MED-50-20 Laboratory, Therapy, and Imaging Radioisotopes 10 CFR 30.51 5 years Records related to the receipt, transfer, use, storage, delivery, disposal, and overexposure of radioisotopes.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 9 of 30
  10. 10. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-50-21 Laboratory, Therapy, and Imaging Laboratory Test Requisitions GS-4 2 years ITEM 95; 42 Requisitions authorizing a laboratory to perform tests on a sample. CFR 493.1105FL-MED-50-22 Laboratory, Therapy, and Imaging Therapy Treatment Records 10 years Records related to therapy treatments that are not duplicated in the patient health records. May include occupational, physical, speech, and inhalation therapy.FL-MED-50-23 Laboratory, Therapy, and Imaging Final Test Reports – Pathology/Histology/Cytology GS-4 10 years ITEM 85; 42 After Date of Laboratory copies of test results and preliminary reports specific to CFR 493.1109 Reporting pathology, histology and cytology.FL-MED-50-24 Laboratory, Therapy, and Imaging Autoclave/Sterile Supply Records 2 years Records related to autoclave/sterile supply.FL-MED-50-25 Laboratory, Therapy, and Imaging 3 years Sterilizers/Monthly Bacteriological Tests Records related to sterilizers and monthly bacteriological tests.FL-MED-50-26 Laboratory, Therapy, and Imaging Patient Testing Reports - Immunohematology/Histocompatibility GS-4 5 years ITEM 84; 42 Immunohematology and histocompatibility specific reports related to the CFR 493.1109 processing, testing, and reporting of patient specimens to assure the accuracy of the testing.FL-MED-50-28 Laboratory, Therapy, and Imaging Laboratory Reports - Complete 42 CFR 5 years 493.1109 Reports documenting each step in the processing, testing, and reporting of patient specimens to assure the accuracy of the testing.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 10 of 30
  11. 11. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-50-30 Laboratory, Therapy, and Imaging Patient Testing Reports– Laboratory Copies GS-4 2 years ITEM 83; 42 Reports documenting each step in the processing, testing, reporting of patient CFR 493.1101 specimens to assure the accuracy of testing, and the loan or referral of slides to another laboratory.FL-MED-50-32 Laboratory, Therapy, and Imaging Tissue Tracking System Records GS-4 Permanent ITEM 99 Records related to the receipt and disposition of all organs and tissues transplanted within the hospital.FL-MED-50-33A Laboratory, Therapy, and Imaging Specimens-Wet Tissue 42 CFR Wet Tissue 7 493.1259 (b) days After Sign OutFL-MED-50-33B Laboratory, Therapy, and Imaging Specimens-Paraffin Blocks 42 CFR 2 years 493.1259 (b)FL-MED-50-33C Laboratory, Therapy, and Imaging 42 CFR 5 years Specimens-Slides 493.1257(g);FL-MED-50-33D Laboratory, Therapy, and Imaging Specimens-Histopathology Slides 42 CFR 10 years 493.1259 (b)FL-MED-50-34 Laboratory, Therapy, and Imaging Specimen Logs 10 years 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.FL-MED-50-35A Laboratory, Therapy, and Imaging Bone Marrow Test Reports-Adults GS-4 Adults 7 ITEMS 80 years After Records related to the testing of bone marrow. Last EntryFL-MED-50-35B Laboratory, Therapy, and Imaging Bone Marrow Test Reports-Minors Minors Age of Majority Records related to the testing of bone marrow. Plus 7 yearsNOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 11 of 30
  12. 12. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-50-36 Laboratory, Therapy, and Imaging Test Procedures 5 years 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.FL-MED-50-37 Laboratory, Therapy, and Imaging Requests for Tests 42 CFR 2 years 493.1105 Includes oral, written, and electronic requests for tests.FL-MED-50-38 Laboratory, Therapy, and Imaging Test Procedures - Discontinued GS-4 4 years After ITEM 103 Procedure is Records of each test procedure with the dates of its initial use and Discontinued discontinuance. May include the test methodology and results, who performed the test, possible side effects, and any necessary equipment.FL-MED-50-39 Laboratory, Therapy, and Imaging Test Procedures - Errors 42 CFR 2 years 493.1219(d)(3) Records include original and corrected reports.FL-MED-50-40 Laboratory, Therapy, and Imaging Echocardiogram Video Tapes 5 years Videotapes created during an echocardiogram.FL-MED-50-41 Laboratory, Therapy, and Imaging 5 years Video Tapes of Diagnostic Tests Videotapes created for other diagnostic tests not listed elsewhere.FL-MED-50-42A Laboratory, Therapy, and Imaging Screening Procedures-Adults GS-4 Adults 7 ITEMS 80 years After Records relating to screening procedures for health risk appraisal, blood Last Entry pressure, blood pressure referral, vision, hearing and speech, diabetics screening, syphilis serology, gonorrhea, and other laboratory screenings and tests.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 12 of 30
  13. 13. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-50-42B Laboratory, Therapy, and Imaging Screening Procedures-Minors Minors Age of Majority Records relating to screening procedures for health risk appraisal, blood Plus 7 years 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 Imaging HIV Test Results 42 CFR 2 years After 493.1109 Date of Records consist of anonymous test results for HIV. ReportingFL-MED-50-46A Laboratory, Therapy, and Imaging Adults 7 HIV Test Results-Adults GS-4 years After ITEMS 80 Last Entry Records consist of seropositive and seronegative confidential test results for HIV.FL-MED-50-46B Laboratory, Therapy, and Imaging HIV Test Results-Minors Minors Age of Majority Records consist of seropositive and seronegative confidential test results for Plus 7 years HIV.FL-MED-50-48A Laboratory, Therapy, and Imaging Screenings for Infant Genetic or Metabolic Disorders-Copies Copies CY+7 years Copies of test results for infant genetic or metabolic disorders. Originals are part of the patient’s medical record.FL-MED-50-48B Laboratory, Therapy, and Imaging Originals Age Screenings for Infant Genetic or Metabolic Disorders-Originals of Majority Plus 7 years Original test results for infant genetic or metabolic disorders. Originals are part of the patient’s medical record.FL-MED-50-50 Laboratory, Therapy, and Imaging Radiology Utilization Logs GS-4 2 years ITEM 117 Logs documenting each source of radiation, the make and model number, storage container, identity of the radiographer, location, and date of its use.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 13 of 30
  14. 14. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-50-52 Laboratory, Therapy, and Imaging Performance Records GS-4 5 years ITEM 94; 42 Reports issued on each laboratorys performances for the individual Medicare, CFR 493.903 Medicaid, and CLIA-licensed specialty or sub-specialty of service after a proficiency test is performed.FL-MED-50-54 Laboratory, Therapy, and Imaging Radiation Equipment – Minor Maintenance GS-4 2 years ITEM 87 Records related to the minor maintenance, daily function checks, routine and package surveys, and instrument calibration performed in accordance with the manufacturers instructions on a Facility’s testing equipment.FL-MED-50-55 Laboratory, Therapy, and Imaging Testing - Unsealed Sources GS-4 3 years ITEM 105 Records related to the testing of unsealed sources of radiation by radiology for leaks or contamination.FL-MED-50-56 Laboratory, Therapy, and Imaging Testing - Sealed Sources GS-4 3 years ITEM 105 Records related to the testing of sealed sources of radiation by radiology for leaks or contamination.FL-MED-50-58 Laboratory, Therapy, and Imaging Sealed Radiation Sources – Inventory GS-4 2 years ITEM 115 Records related to staff conducting physical inventories to account for all sealed radiation sources received or possessed under an appropriate license.FL-MED-50-60 Laboratory, Therapy, and Imaging Inspections – Radiology GS-4 2 years After ITEM 101 Compliance Records related to federal, state, and/or consulting physicists 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.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 14 of 30
  15. 15. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-50-62 Laboratory, Therapy, and Imaging Testing Entry Control Devices GS-4 3 years ITEM 114 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.FL-MED-50-64 Laboratory, Therapy, and Imaging Radiation Protection Program – Audits GS-4 3 years ITEM 108 Records related to the audits or reviews on the Radiation Protection Program.FL-MED-50-66 Laboratory, Therapy, and Imaging Radiation Protection Program GS-4 1 year After ITEM 124 Termination Records documenting the prevention of unnecessary radiological exposure to or Expiration humans and the environment. of LicenseFL-MED-50-67 Laboratory, Therapy, and Imaging Radiation Protection Program – Misadministration 5 years Records documenting the misadministration of dosages including wrong patient, dosage differences from prescribed dosages, and wrong mode of treatment.FL-MED-50-68 Laboratory, Therapy, and Imaging Credential License and Certification Records GS-4 7 years After ITEM 100 Separation or Credentials, licenses, and certifications of each person providing diagnostic Termination and therapeutic radiation, imaging, and nuclear medicine services including of formal training, on the job education, and continuing educational credits. EmploymentFL-MED-50-70 Laboratory, Therapy, and Imaging Planned Special Exposure GS-4 1 year After ITEM 112 Termination Records documenting planned and authorized radiological exposure. or Expiration of LicenseFL-MED-50-72 Laboratory, Therapy, and Imaging Environmental Exposure GS-4 1 year After ITEM 123 Termination Records documenting the results of measurements and calculations used to or Expiration evaluate the release of radioactive effluents into the environment. of LicenseNOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 15 of 30
  16. 16. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-50-74 Laboratory, Therapy, and Imaging Radiation Monitoring Records – Human Exposure GS-4 1 year After ITEM 88 Termination Records related to the monitoring of annual doses received by individuals, the or Expiration doses received during planned special exposures, accidents, and emergency of License 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.FL-MED-50-76 Laboratory, Therapy, and Imaging Radiation Detection Instrumentation GS-4 3 years ITEM 86 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.FL-MED-50-78 Laboratory, Therapy, and Imaging Radiation Monitoring Records – Radioactive Materials GS-4 3 years ITEM 104 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.FL-MED-50-80 Laboratory, Therapy, and Imaging Radiology Surveys GS-4 3 years ITEM 106 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.FL-MED-50-81 Laboratory, Therapy, and Imaging Nuclear Medicine Reports 10 years Includes nuclear medicine interpretations, consultations, and procedures.FL-MED-50-82 Laboratory, Therapy, and Imaging Images of Computed Tomography Until a New Dose Images of spot checks for computed tomography x-ray systems. Measurement is PerformedNOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 16 of 30
  17. 17. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-50-84 Laboratory, Therapy, and Imaging Therapeutic X-Ray Systems of less than 1MeV 2 years Records of the calibrations of the therapy system.FL-MED-50-86 Laboratory, Therapy, and Imaging Therapeutic X-Ray Systems of more than 1MeV 2 years Records of the calibrations of the therapy system and of the dosimetry system.FL-MED-50-88 Laboratory, Therapy, and Imaging Mammograms 10 years Original mammograms.FL-MED-50-90 Laboratory, Therapy, and Imaging Mammogram File – Single Visit GS-4 10 years ITEM 90 X-ray film that is the ONLY mammogram taken. Retention is for the actual film not the radiologists interpretation of film. The interpretation is part of the Patient Medical Record. For more than one mammogram see FL- MED-60-06.FL-MED-50-92 Laboratory, Therapy, and Imaging Mammography - Quality Assurance 3 years 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.FL-MED-50-94 Laboratory, Therapy, and Imaging Mammography Facility – Complaint Records GS-4 7 years After ITEM 91 Investigation Complaints filed by employees or patients against a mammography provider and the results of the accrediting bodys investigations.FL-MED-50-96 Laboratory, Therapy, and Imaging Mammography – Quality Control Surveys GS-4 1 calendar ITEM 92 year Survey reports conducted annually to assure that the facility meets specified quality control and equipment standards.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 17 of 30
  18. 18. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-55-02 Facility/Departmental Records Administrative Files CY+3 years Administrative records for individual facility records.FL-MED-55-03 Facility/Departmental Records Inventory and Orders 2 years Includes records of inventories of supplies ordered, maintained, and used by individual departments. For controlled substances see FL-MED-80-02.FL-MED-55-04 Facility/Department Records Department Log Books CY+3 years Log books for individual facility departments not listed elsewhere.FL-MED-55-06 Facility/Department Records QC Reports 5 years Quality control reports for individual facility departments.FL-MED-55-08 Facility/Department Records Medical Procedure Manuals GS-4 7 years After ITEM 120 SUP Manuals for medical equipment and procedures that are kept within specific facility departments.FL-MED-55-10 Facility/Department Records Infection Control Program Records GS-4 CY+5 years ITEM 74 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.FL-MED-55-12 Facility/Department Records Respiratory Protection Program GS-4 1 year After ITEM 107 Termination Records related to Respiratory Protection Programs. or Expiration of LicenseNOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 18 of 30
  19. 19. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-55-14 Facility/Department Records Training and Education Records ACT+3 years Records related to training and certification of employees, which does not include radiological, diagnostic imaging, nuclear medicine training, or nursing.FL-MED-55-16 Facility/Department Records Immunohematology - Quality Control Records GS-4 5 years ITEM 82; 42 Records related to the quality control of immunohematology sample CFR 493.1221; processing and testing to assure that the samples were tested in the same exact 21 CFR 606.160 manner as the regular patient samples.FL-MED-55-18 Facility/Department Records Laboratory - Quality Control Records GS-4 2 years ITEM 81; 42 Records related to the quality control of laboratory sample processing and CFR 493.1221(a) testing to assure that the samples were tested in the same exact manner as the regular patient samples.FL-MED-55-20 Facility/Department Records Chart Audits 1 year Internal audits and related work-papers performed on patient charts.FL-MED-55-22 Facility/Department Records Intensive Care Unit Logs 10 years Log created and maintained by the Intensive Care Unit of a facility.FL-MED-55-24 Facility/Department Records Implant Logs 10 years Implant logs listing items implanted into patients during surgical procedures.FL-MED-55-26 Facility/Department Records Delivery Room Logs GS-4 10 years ITEM 23 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.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 19 of 30
  20. 20. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-55-28 Facility/Department Records Operating Room Schedules 3 years Schedules of procedures performed in an operating room.FL-MED-55-30 Facility/Department Records X-Ray Logs GS-4 10 years ITEM 98 X-ray logs include name of patient, type of examination, date of the exam, and technician performing the service.FL-MED-55-32 Facility/Department Records Ambulance Records 2 years Records related to the use of an ambulance in transporting patients.FL-MED-55-34 Facility/Department Records Air Ambulance Safety Committee Meeting Minutes GS-4 2 years ITEM 125 Records detailing the proceedings of the Air Ambulance Safety Committee.FL-MED-55-38 Facility/Department Records Special Procedures Unit CY+ 3 years Records related to endoscopies, and other outpatient surgeries. Include patient arrival and departure times and is documented in the patient’s medical file.FL-MED-58-02 Medical Research Records Research Papers – Published Permanent Published papers from medical staff.FL-MED-58-04 Medical Research Records Human Experimentation Records 30 years Beyond Records related to experimental drugs and devices. Experiment, Patient Medical Records Should be Retained for Same PeriodNOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 20 of 30
  21. 21. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-58-06 Medical Research Records Research Reports 10 years Reports related to medical research.FL-MED-60-01 Health Records Patient Medical Records – Nursing Home Minors GS-4 Retain Until ITEM 133 24 years of Complete health records for patients seeking care or service from a nursing Age or 7 home provider. years After Last Entry, Whichever is LongerFL-MED-60-02 Health Records Patient Medical Records – Adults GS-4 7 years After ITEM 80 Last Entry Complete health records for adult patients.FL-MED-60-03 Health Records Patient Medical Records – Children Under One Year Of Age Minors Age of Majority Complete health records for children under one year of age. Plus 7 yearsFL-MED-60-04 Health Records Patient Medical Records – Minors Over One Year of Age GS-4 Minors Age ITEM 80 of Majority Complete health records for minors. Plus 7 yearsFL-MED-60-05A Health Records Psychiatric Records-Adults GS-4 Adults 7 ITEM 80 years After Psychiatric evaluations and treatment provided to patients. Last EntryFL-MED-60-05B Health Records Psychiatric Records-Minors Minors Age of Majority Psychiatric evaluations and treatment provided to patients. Plus 7 yearsNOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 21 of 30
  22. 22. Record Series TotalCode Record Series Title & Description Legal Citation RetentionFL-MED-60-06A Health Records Diagnostic Images GS-4 7 years ITEM 78 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.FL-MED-60-07 Health Records Patient Transfer Records 42 USC 5 years From 1395cc(a)(1)(I) Date of Records related to the patient transfer to and from the hospital. Information is (ii) Transfer in the Patient Medical Record.FL-MED-60-08 Health Records Fetal Heart Monitor Records GS-4 Minors Age ITEM 130 of Majority Records related to fetal heart monitoring. Includes actual strips generated by Plus 7 years fetal heart monitors and testing devices.FL-MED-60-10 Health Records Disease Index, Operative Index, Physician’s Index, Diagnostic Index, GS-4 Permanent Number Index ITEM 60 Health records indexes for disease, operations, and physicians.FL-MED-60-12 Health Records Master Patient Index GS-4 Permanent ITEM 49 Master index to patient health records.FL-MED-60-14 Health Records Register of Births Permanent Register detailing all births including still births occurring at the facility.FL-MED-60-16 Health Records Register of Deaths Permanent Register detailing all deaths occurring at the facility.FL-MED-60-18 Health Records Register of Surgical Procedures Permanent Register detailing all surgical procedures performed at the facility.NOTE: CFR = Code of Federal Regulations, USC = United State Code, GS-4 = State of Florida General Records Schedule for Public Hospitals, Health CareFacilities 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 valueApproved: August 15, 2000Revised: September 10, 2003 22 of 30

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