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HCA
Record Retention Schedule – Medical/Facility Records
State of Mississippi
For general accounting and payroll records, ...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
MS-MED-10-05 Administrative Offices
Ho...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Official register of all patient admis...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
MS-MED-10-29 Administrative Offices
Pa...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Inspection Reports Minimum
Standards f...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Social Service Confidential Case Histo...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Blood Bank – Blood Donor Records
Recor...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Records related to the final dispositi...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
echocardiogram monitors and testing de...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
electromyogram monitors and testing de...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Records related to sterilizers and mon...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Individual department specimen logs do...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Videotapes created during an echocardi...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Screenings for Infant Genetic or Metab...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Sealed Radiation Sources – Inventory
R...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Records documenting planned and author...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Includes nuclear medicine interpretati...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Mammography – Quality Control Surveys
...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Records related to training and certif...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
X-Ray Logs
X-ray logs include name of ...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Complete health records for adult pati...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
MS-MED-60-10 Health Records
Disease In...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
MS-MED-60-22 Health Records
Records of...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Discharged at
Death 7 years
MS-MED-60-...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Records consist of observations and no...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
substances. Hospitals 2002.1,
2002.2, ...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Radioactive Drugs
Includes inventory a...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Biomedical Waste – Exception Form
Reco...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
Blueprints and Construction Drawings
B...
Record Series
Code Record Series Title & Description Legal Citation
Total
Retention
FCC license, etc. License Plus 6
years...
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Mississippi Medical/Facility Records Retention Schedule.doc.doc

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Mississippi Medical/Facility Records Retention Schedule.doc.doc

  1. 1. HCA Record Retention Schedule – Medical/Facility Records State of Mississippi For general accounting and payroll records, please reference Accounting Retention Schedule. For general personnel records, please reference Human Resources Retention Schedule. For general administrative records, please reference Administrative Retention Schedule. For general legal records, please reference Legal Retention Schedule. For general information systems records, please reference Information Systems Retention Schedule. For patient accounting records, please reference Patient Account Services Schedule. The record retention listed is for the official record copy. Duplicates should be retained until obsolete, superseded, or administrative value is lost. The official record copy may be in hardcopy, electronic, and/or microform format. If the hardcopy is the original record and is scanned into an imaging system, the hardcopy should be retained for the duration of the retention until further notice. Record Series Code Record Series Title & Description Legal Citation Total Retention MS-MED-10-01 Administrative Offices Annual Reports to State Departments of Health Minimum Standards for Hospitals 201.1 Permanent MS-MED-10-02 Administrative Offices Birth Records to Local Government Records consist of copies of vital birth records and certificates filed with state registrar of vital statistics. Permanent MS-MED-10-04 Administrative Offices Daily Census Daily patient census data. CY+5 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 1 of 31
  2. 2. Record Series Code Record Series Title & Description Legal Citation Total Retention MS-MED-10-05 Administrative Offices Hospital Permits Required permits to operate a hospital. MS Code § 41-9- 11; MS Code § 41-9-81 Retain Until Suspended or Revoked MS-MED-10-06 Administrative Offices Communicable Disease Reports Reports related to communicable diseases. MS Code § 41-23- 1 (4), (5) CY+3 years MS-MED-10-07 Administrative Offices Medical Staff Files Medical staff files including certification, credentials, complaints and continuing medical education records. Minimum Standards for Hospitals 501 Life of Hospital MS-MED-10-08 Administrative Offices Constitution and Medical Staff Bylaws Records documenting the terms, conditions, and procedures by which the facility will operate. MS Code § 41-9- 81; Minimum Standards for Hospitals 301, 406, 502.1, 506.1 Life of Hospital MS-MED-10-09 Administrative Offices Minutes of Board of Directors, Executive Committee, Medical Staff Records detailing the proceedings of board of directors, executive committee, and medical staff meetings. For department, committee, or project meetings use ADM-90-09. MS Code § 41-9- 81; Minimum Standards for Hospitals 504 Life of Hospital MS-MED-10-10 Administrative Offices Death Records to Local Government Copies of death records required by local government. MS Code § 41-23- 1(2), (3) Permanent MS-MED-10-11 Administrative Offices Death Records Records that track the transfer of corpses from the hospital to outside locations. CY+3 years MS-MED-10-12 Administrative Offices Statistics on Admissions, Services, and Discharges Statistical data compiled into various reports detailing patient admissions, services rendered, transfers, leave of absences, and discharges. 42 USC 1395cc(a) (1)(I) (ii) CY+6 years MS-MED-10-14 Administrative Offices Admissions/Discharges Register CY+6 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 2 of 31
  3. 3. Record Series Code Record Series Title & Description Legal Citation Total Retention Official register of all patient admissions and discharges. MS-MED-10-16 Administrative Offices Medical Equipment Logs Records detailing the type, model, location, and usage of medical equipment. Includes maintenance, scheduled function checks, and instrument calibration performed in accordance with the manufacturer’s instructions. CY+3 years MS-MED-10-20 Administrative Offices Accreditation Surveys and Reports Records related to accreditation surveys and results. Includes inspection reports by accrediting institutions, notices of corrections, correction reports, activity calendars, in-house surveys, and testing done prior to the actual accreditation survey. MS Code § 41-63- 21 5 years After Next Accreditation is Issued MS-MED-10-22 Administrative Offices Medical Directives, Policy and Procedure Manuals Directives, policies, and procedures for facility operations. Includes emergency code procedures and cards. 7 years After SUP MS-MED-10-24 Administrative Offices Training Programs Records related to classes and training programs provided to patients and customers by clinical staff. Includes Lamaze, CPR, and first aid. ACT+3 years MS-MED-10-25 Administrative Offices Employee Training Records related to employee training provided on hazards and use of pesticides. 3 years After Separation From Job MS-MED-10-26 Administrative Offices Volunteer Records Records related to work activities of volunteers at facilities. Includes work schedules, location, and duties performed. 2 years After Termination MS-MED-10-28 Administrative Offices Deceased Patients Property Disposition Records relating to the disposition of deceased patient’s personal property. CY+3 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 3 of 31
  4. 4. Record Series Code Record Series Title & Description Legal Citation Total Retention MS-MED-10-29 Administrative Offices Patient Personal Property Inventory 3 years After Discharge MS-MED-10-30 Administrative Offices Inspection Reports Reports of inspection by local, state, or federal agents. 10 CFR 30.51 CY+5 years MS-MED-10-32 Administrative Offices OSHA Records Records include logs, summaries, and OSHA forms 102/102a. 29 CFR 1904.6 5 years MS-MED-10-34 Administrative Offices Pastoral Visitation Log CY+3 years MS-MED-12-02 Housekeeping Records Autoclave Records Adopted Standards for the Regulation of Medical Waste II.B.5 2 years MS-MED-12-04 Housekeeping Records Checkout, Transfer, Isolation Records 2 years MS-MED-12-06 Housekeeping Records Cleaning Records Minimum Standards for Hospitals 1502 2 years MS-MED-12-08 Housekeeping Records Linen Poundage Report 2 years MS-MED-12-10 Housekeeping Records Exterminator Records CY+5 years MS-MED-30-02 Dietary Records Food Costs Records related to the purchase and cost of food and food services. CY+5 years MS-MED-30-04 Dietary Records Menus 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. 1 year MS-MED-30-05 Dietary Records NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 4 of 31
  5. 5. Record Series Code Record Series Title & Description Legal Citation Total Retention Inspection Reports Minimum Standards for Hospitals 1302.1 Retain 1 year After SUP MS-MED-30-06 Dietary Records Dietary Recipe Records Standardized dietary recipe records used in the preparation of patient meals by the kitchen staff. Includes a nutritional analysis, ingredients list, and serving size notation. Minimum Standards for Hospitals 1303 AV MS-MED-30-08 Dietary Records Dietician Counseling Summaries Annual summaries provided by a nutritionist or dietitian that evaluate the menus, sanitation, policies and procedures, and recommend modifications for the food preparation and service. 2 years MS-MED-30-10 Dietary Records Inservice Training Records Minimum Standards for Hospitals 1301.6 ACT+3 years MS-MED-30-12 Dietary Records Bacteriological Testing of Ice 2 years MS-MED-30-14 Dietary Records Meal Counts 1 year MS-MED-40-02 Clinic Records Appointment Books Patient appointment books that record the appointment time and patient name. CY+3 years MS-MED-40-04 Clinic Records Encounter Statistics Statistical data for clinic encounters. CY+5 years MS-MED-40-06A Clinic Records Social Service Confidential Case Histories-Adults Clinic patients social service case histories. MS Code § 41-9- 69 (1); Minimum Standards for Hospitals 2201 Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-40-06B Clinic Records NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 5 of 31
  6. 6. Record Series Code Record Series Title & Description Legal Citation Total Retention Social Service Confidential Case Histories-Minors Clinic patients social service case histories. MS Code § 41-9- 69 (1); Minimum Standards for Hospitals 2201 Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-40-08A Clinic Records Welfare Agency Records-Adults Clinic records related to welfare agencies. MS Code § 41-9- 69 (1) Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-40-08B Clinic Records Welfare Agency Records-Minors Clinic records related to welfare agencies. MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-50-02 Laboratory, Therapy, and Imaging Blood Bank – Adverse Reactions to Transfusions Records related to adverse reactions to blood transfusions. 21 CFR 606.160 5 years After Processing or 6 Months After the Latest Expiration Date for the Individual Product, Whichever is Longer MS-MED-50-03 Laboratory, Therapy, and Imaging Blood 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. Minimum Standards for Hospitals 1910.7; 21 CFR 606.160 5 years After Processing or 6 Months After the Latest Expiration Date, If There is No Expiration Date Records are Retained Permanently MS-MED-50-04 Laboratory, Therapy, and Imaging NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 6 of 31
  7. 7. Record Series Code Record Series Title & Description Legal Citation Total Retention Blood Bank – Blood Donor Records Records related to blood donors including histories, examinations, consent, reactions, donor selection, results of required tests performed on plasmpheresis and cytopheresis donors, permanent and temporary deferrals, investigation and follow-up, therapeutic bleedings, immunization, and blood collection. 21 CFR 606.160 5 years After Processing or 6 Months After the Latest Expiration Date, If There is No Expiration Date Records are Retained Permanently MS-MED-50-06 Laboratory, Therapy, and Imaging Blood Bank – ABO and RH Types Records related to type testing of blood. 21 CFR 606.160 5 years After Processing or 6 Months After the Latest Expiration Date, If There is No Expiration Date Records are Retained Permanently MS-MED-50-07 Laboratory, Therapy, and Imaging Blood 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. 21 CFR 606.160 5 years After Processing or 6 Months After the Latest Expiration Date, If There is No Expiration Date Records are Retained Permanently MS-MED-50-08 Laboratory, Therapy, and Imaging Blood Bank – Blood Test Results Records related to blood test results including interpretations and release data for compatibility testing. 21 CFR 606.160 5 years After Processing or 6 Months After the Latest Expiration Date, If There is No Expiration Date Records are Retained Permanently MS-MED-50-10 Laboratory, Therapy, and Imaging Blood Bank – Final Disposition of Blood and Components Minimum 5 years After NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 7 of 31
  8. 8. Record Series Code Record Series Title & Description Legal Citation Total Retention Records related to the final disposition of blood and blood components. Standards for Hospitals 1910.7; 21 CFR 606.160 Processing or 6 Months After the Latest Expiration Date, If There is No Expiration Date Records are Retained Permanently MS-MED-50-12 Laboratory, Therapy, and Imaging Blood Bank – Refrigeration and Blood Inspection Records Records detailing blood inspection and refrigeration. 21 CFR 606.160 5 years After Processing or 6 Months After the Latest Expiration Date, If There is No Expiration Date Records are Retained Permanently MS-MED-50-14 Laboratory, Therapy, and Imaging Blood Bank – Transfusion Request Records Transfusion requests received by the blood bank. 21 CFR 606.160 5 years After Processing or 6 Months After the Latest Expiration Date, If There is No Expiration Date Records are Retained Permanently MS-MED-50-15A Laboratory, Therapy, and Imaging Echocardiogram Tracings-Adults Patient echocardiogram tracing. Includes actual strips generated by echocardiogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record. MS Code § 41-9- 69 (1) Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-50-15B Laboratory, Therapy, and Imaging Echocardiogram Tracings-Minors Patient echocardiogram tracing. Includes actual strips generated by MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 8 of 31
  9. 9. Record Series Code Record Series Title & Description Legal Citation Total Retention echocardiogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record. to Exceed 28 years MS-MED-50-16A Laboratory, Therapy, and Imaging Electrocardiogram Tracings-Adults Patient electrocardiogram tracings. Includes actual strips generated by electrocardiogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record. MS Code § 41-9- 69 (1) Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-50-16B Laboratory, Therapy, and Imaging Electrocardiogram Tracings-Minors Patient electrocardiogram tracings. Includes actual strips generated by electrocardiogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record. MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-50-18A Laboratory, Therapy, and Imaging Electroencephalogram Tracings-Adults Patient electroencephalogram tracings. Includes actual strips generated by electroencephalogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record. MS Code § 41-9- 69 (1) Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-50-18B Laboratory, Therapy, and Imaging Electroencephalogram Tracings-Minors Patient electroencephalogram tracings. Includes actual strips generated by electroencephalogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record. MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-50-19A Laboratory, Therapy, and Imaging Electromyograms Tracings-Adults Patient electromyogram tracings. Includes actual strips generated by electromyogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record. MS Code § 41-9- 69 (1) Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-50-19B Laboratory, Therapy, and Imaging Electromyograms Tracings-Minors Patient electromyogram tracings. Includes actual strips generated by MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 9 of 31
  10. 10. Record Series Code Record Series Title & Description Legal Citation Total Retention electromyogram monitors and testing devices where a report or interpretation has been recorded in the patient medical record. to Exceed 28 years MS-MED-50-20 Laboratory, Therapy, and Imaging Radioisotopes Records related to the receipt, transfer, use, storage, delivery, disposal, and overexposure of radioisotopes. MS Code § 45-14- 19 (1) (a); Mississippi Radiological Health Regulations 801.A.4; 10 CFR 30.51 5 years MS-MED-50-21 Laboratory, Therapy, and Imaging Laboratory Test Requisitions Requisitions authorizing a laboratory to perform tests on a sample. 42 CFR 493.1105 2 years MS-MED-50-22A Laboratory, Therapy, and Imaging Therapy Treatment Records-Adults Records related to therapy treatments that are not duplicated in the patient health records. May include occupational, physical, speech, and inhalation therapy. MS Code § 41-9- 69 (1); Minimum Standards for Hospitals 1803.7 Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-50-22B Laboratory, Therapy, and Imaging Therapy Treatment Records-Minors Records related to therapy treatments that are not duplicated in the patient health records. May include occupational, physical, speech, and inhalation therapy. MS Code § 41-9- 69 (1); Minimum Standards for Hospitals 1803.7 Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-50-23 Laboratory, Therapy, and Imaging Final Test Reports – Pathology/Histology/Cytology Laboratory copies of test results and preliminary reports specific to pathology, histology and cytology. Includes histology and pathology specimen logs and slides. 42 CFR 493.1109; 42 CFR 493.1257 10 years After Date of Reporting MS-MED-50-24 Laboratory, Therapy, and Imaging Autoclave/Sterile Supply Records Records related to autoclave/sterile supply. Adopted Standards for the Regulation of Medical Waste II.B.5 2 years MS-MED-50-25 Laboratory, Therapy, and Imaging Sterilizers/Bacteriological Tests 3 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 10 of 31
  11. 11. Record Series Code Record Series Title & Description Legal Citation Total Retention Records related to sterilizers and monthly bacteriological tests. Includes recording charts, chemical indicators, Bonne-Dick tests, readings from jacket pressure gauge, and chamber pressure gauge. MS-MED-50-26 Laboratory, Therapy, and Imaging Patient Testing Reports – Immunohematology/Histocompatibility Immunohematology and histocompatibility specific reports related to the processing, testing, and reporting of patient specimens to assure the accuracy of the testing. 42 CFR 493.1109 5 years MS-MED-50-28 Laboratory, Therapy, and Imaging Laboratory Reports – Complete Reports documenting each step in the processing, testing, and reporting of patient specimens to assure the accuracy of the testing. 42 CFR 493.1109 5 years MS-MED-50-30 Laboratory, Therapy, and Imaging Patient Testing Reports – Laboratory Copies Reports documenting each step in the processing, testing, and reporting of patient specimens to assure the accuracy of testing, and the loan or referral of slides to another laboratory. Minimum Standards for Hospitals 1906.1; 42 CFR 493.1101 2 years MS-MED-50-32 Laboratory, Therapy, and Imaging Tissue Tracking System Records Records related to the receipt and disposition of all organs and tissues transplanted within the hospital. Minimum Standards for Hospitals 1908.4 Permanent MS-MED-50-33A Laboratory, Therapy, and Imaging Specimens-Wet Tissue 42 CFR 493.1259 (b) 7 days After Sign Out MS-MED-50-33B Laboratory, Therapy, and Imaging Specimens-Paraffin Blocks 42 CFR 493.1259 (b) 2 years MS-MED-50-33C Laboratory, Therapy, and Imaging Specimens-Slides 42 CFR 493.1257(g) 5 years MS-MED-50-33D Laboratory, Therapy, and Imaging Specimens-Histopathology Slides 42 CFR 493.1259 (b) 10 years MS-MED-50-34 Laboratory, Therapy, and Imaging Specimen Logs 10 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 11 of 31
  12. 12. Record Series Code Record Series Title & Description Legal Citation Total Retention Individual department specimen logs documenting the receipt of specimens to the lab, procedures performed, results obtained, and the disposition of the specimen. It does not become part of the patient’s medical file or the tissue tracking system records. MS-MED-50-35A Laboratory, Therapy, and Imaging Bone Marrow Test Reports-Adults Records related to the testing of bone marrow. MS Code § 41-9- 69 (1) Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-50-35B Laboratory, Therapy, and Imaging Bone Marrow Test Reports-Minors Records related to the testing of bone marrow. MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-50-36 Laboratory, Therapy, and Imaging Test Procedures Copies of each test procedure with the date of its initial use. May include the test methodology and results, who performed the test, possible side effects, and any necessary equipment. 5 years MS-MED-50-37 Laboratory, Therapy, and Imaging Requests for Tests Includes oral, written, and electronic requests for tests. Minimum Standards for Hospitals 1905.2; 42 CFR 493.1105 2 years MS-MED-50-38 Laboratory, Therapy, and Imaging Test Procedures – Discontinued Records of each test procedure with the dates of its initial use and discontinuance. May include the test methodology and results, who performed the test, possible side effects, and any necessary equipment. 4 years After Procedure is Discontinued MS-MED-50-39 Laboratory, Therapy, and Imaging Test Procedures – Errors Records include original and corrected reports. 42 CFR 493.1219(d)(3) 5 years MS-MED-50-40 Laboratory, Therapy, and Imaging Echocardiogram Video Tapes 5 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 12 of 31
  13. 13. Record Series Code Record Series Title & Description Legal Citation Total Retention Videotapes created during an echocardiogram. MS-MED-50-41 Laboratory, Therapy, and Imaging Video Tapes of Diagnostic Tests Videotapes created for other diagnostic tests not listed elsewhere. 5 years MS-MED-50-42A Laboratory, Therapy, and Imaging Screening Procedures-Adults Records relating to screening procedures for health risk appraisal, blood pressure, blood pressure referral, vision, hearing and speech, diabetics screening, syphilis serology, gonorrhea, and other laboratory screenings and tests. MS Code § 41-9- 69 (1) Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-50-42B Laboratory, Therapy, and Imaging Screening Procedures-Minors Records relating to screening procedures for health risk appraisal, blood pressure, blood pressure referral, vision, hearing and speech, diabetics screening, syphilis serology, gonorrhea, and other laboratory screenings and tests. MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-50-44 Laboratory, Therapy, and Imaging HIV Test Results Records consist of anonymous test results for HIV. 42 CFR 493.1109 2 years After Date of Reporting MS-MED-50-46A Laboratory, Therapy, and Imaging HIV Test Results-Adults Records consist of seropositive and seronegative confidential test results for HIV. MS Code § 41-9- 69 (1) Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-50-46B Laboratory, Therapy, and Imaging HIV Test Results -Minors Records consist of seropositive and seronegative confidential test results for HIV. MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-50-48A Laboratory, Therapy, and Imaging NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 13 of 31
  14. 14. Record Series Code Record Series Title & Description Legal Citation Total Retention Screenings for Infant Genetic or Metabolic Disorders-Copies Copies of test results for infant genetic or metabolic disorders. Originals are maintained in the patient’s medical record. MS Code § 41-9- 69 (1) Copies 2 years MS-MED-50-48B Laboratory, Therapy, and Imaging-Originals Screenings for Infant Genetic or Metabolic Disorders-Originals Original test results for infant genetic or metabolic disorders. Originals are maintained in the patient’s medical record. MS Code § 41-9- 69 (1) Originals Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-50-50 Laboratory, Therapy, and Imaging Radiology Utilization Logs Logs documenting each source of radiation, the make and model number, storage container, identity of the radiographer, location, and date of its use. 5 years MS-MED-50-52 Laboratory, Therapy, and Imaging Performance Records Reports issued on each laboratory's performances for the individual Medicare, Medicaid, and CLIA-licensed specialty or sub-specialty of service after a proficiency test is performed. 42 CFR 493.903 5 years MS-MED-50-54 Laboratory, Therapy, and Imaging Radiation Equipment – Minor Maintenance Records related to the minor maintenance, daily function checks, routine and package surveys, and instrument calibration performed in accordance with the manufacturer's instructions on a Facility’s testing equipment. 2 years After Completion of Calibration MS-MED-50-55 Laboratory, Therapy, and Imaging Testing – Unsealed Sources Records related to the testing of unsealed sources of radiation by radiology for leaks or contamination. Mississippi Radiological Health Regulations 801.C.22 (d) (3) (iv) 3 years From the Date of the Recorded Event or Until the Device is Transferred or Disposed of MS-MED-50-56 Laboratory, Therapy, and Imaging Testing – Sealed Sources Records related to the testing of sealed sources of radiation by radiology for leaks or contamination. Mississippi Radiological Health Regulations 801.C.22 (d) (3) (iv) 3 years From the Date of the Recorded Event or Until the Device is Transferred or Disposed of MS-MED-50-58 Laboratory, Therapy, and Imaging NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 14 of 31
  15. 15. Record Series Code Record Series Title & Description Legal Citation Total Retention Sealed Radiation Sources – Inventory Records related to staff conducting physical inventories to account for all sealed radiation sources received or possessed under an appropriate license. 2 years MS-MED-50-60 Laboratory, Therapy, and Imaging Inspections – Radiology Records related to federal, state, and/or consulting physicist's inspections of the radiological services area. Includes tests on protective equipment such as aprons, gloves, and shields, and any actions taken to correct the identified deficiencies. Minimum Standards for Hospitals 2102.3; Mississippi Radiological Health Regulations 801.A.5 5 years MS-MED-50-62 Laboratory, Therapy, and Imaging Testing Entry Control Devices Records related to the testing of the entry control devices to secured areas housing high levels of radiation. Includes date, time and results of each test. 2 years MS-MED-50-64 Laboratory, Therapy, and Imaging Radiation Protection Program – Audits Records related to the audits or reviews on the Radiation Protection Program. 3 years MS-MED-50-66 Laboratory, Therapy, and Imaging Radiation Protection Program Records documenting the prevention of unnecessary radiological exposure to humans and the environment. Mississippi Radiological Health Regulations 801.C.24 (h) (3) 5 years MS-MED-50-67 Laboratory, Therapy, and Imaging Radiation Protection Program – Misadministration Records documenting the misadministration of dosages including wrong patient, dosage differences from prescribed dosage, and wrong mode of treatment. Mississippi Radiological Health Regulations 801.A.7 5 years MS-MED-50-68 Laboratory, Therapy, and Imaging Credential License and Certification Records Credentials, licenses, and certifications of each person providing diagnostic and therapeutic radiation, imaging, and nuclear medicine services including formal training, on the job education, and continuing educational credits. 7 years After Separation or Termination of Employment MS-MED-50-70 Laboratory, Therapy, and Imaging Planned Special Exposure 1 year After NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 15 of 31
  16. 16. Record Series Code Record Series Title & Description Legal Citation Total Retention Records documenting planned and authorized radiological exposure. Termination or Expiration of License MS-MED-50-72 Laboratory, Therapy, and Imaging Environmental Exposure Records documenting the results of measurements and calculations used to evaluate the release of radioactive effluents into the environment. 3 years MS-MED-50-74 Laboratory, Therapy, and Imaging Radiation Monitoring Records – Human Exposure Records related to the monitoring of annual doses received by individuals, the doses received during planned special exposures, accidents, and emergency conditions. Includes adults and minors who receive in excess of their limitations in a single year and individuals entering a high or very high radiation area. May include surveys of radiation for determining an individual’s dose from external sources. MS Code § 45-14- 19 (1) (b); Mississippi Radiological Health Regulations 801.J.13 (b) 3 years MS-MED-50-76 Laboratory, Therapy, and Imaging Radiation Detection Instrumentation Records related to the calibration of radiation detection instruments that measure the radiation levels in the environment, on humans, and objects. Includes dates and times of inspections, repairs, and dates in and out of service. 2 years After Completion of Calibration MS-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. 2 years After Completion of Calibration MS-MED-50-80 Laboratory, Therapy, and Imaging Radiology Surveys Records related to surveys to evaluate radiation levels, concentrations or quantities of radioactive materials, and potential radioactive hazards that could be present. Includes surveys of physical radiation for the purpose of determining whether each sealed source is in its shielded position prior to securing the radiographic device, storage container, or source changes in a storage area. The entire device is surveyed including the source guide tube. 3 years MS-MED-50-81 Laboratory, Therapy, and Imaging Nuclear Medicine Reports 5 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 16 of 31
  17. 17. Record Series Code Record Series Title & Description Legal Citation Total Retention Includes nuclear medicine interpretations, consultations, and procedures. MS-MED-50-82 Laboratory, Therapy, and Imaging Images of Computed Tomography Images of spot checks for computed tomography x-ray systems. Until a New Dose Measurement is Performed MS-MED-50-84 Laboratory, Therapy, and Imaging Therapeutic X-Ray Systems of less than 1MeV Records of the calibrations of the therapy system. 2 years After Completion of Calibration MS-MED-50-86 Laboratory, Therapy, and Imaging Therapeutic X-Ray Systems of more than 1MeV Records of the calibrations of the therapy system and of the dosimetry system. 2 years After Completion of Calibration MS-MED-50-88 Laboratory, Therapy, and Imaging Mammograms Original mammograms. 10 years MS-MED-50-90 Laboratory, Therapy, and Imaging Mammogram File – Single Visit X-ray film that is the ONLY mammogram taken. Retention is for the actual film not the radiologist's interpretation of film. The interpretation is part of the Patient Medical Record. For more than one mammogram see MS-MED- 60-06. 10 years MS-MED-50-92 Laboratory, Therapy, and Imaging Mammography – Quality Assurance Records related to the quality assurance for mammography systems. Includes annual review of quality assurance program, documentation of equipment monitoring, checks of quality control items, and any necessary corrections. 3 years MS-MED-50-94 Laboratory, Therapy, and Imaging Mammography Facility – Complaint Records Complaints filed by employees or patients against a mammography provider and the results of the accrediting body's investigations. 7 years After Investigation MS-MED-50-96 Laboratory, Therapy, and Imaging NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 17 of 31
  18. 18. Record Series Code Record Series Title & Description Legal Citation Total Retention Mammography – Quality Control Surveys Survey reports conducted annually to assure that the facility meets specified quality control and equipment standards. 3 years MS-MED-55-02 Facility/Departmental Records Administrative Files Administrative records for individual facility records. CY+3 years MS-MED-55-03 Facility/Departmental Records Inventory and Orders Includes records of inventories of supplies ordered, maintained, and used by individual departments. For controlled substances see MS-MED-80-02. 2 years MS-MED-55-04 Facility/Department Records Department Log Books Log books for individual facility departments not listed elsewhere. CY+3 years MS-MED-55-06 Facility/Department Records QC Reports Quality control reports for individual facility departments. CY+5 years MS-MED-55-08 Facility/Department Records Medical Procedure Manuals Manuals for medical equipment and procedures that are kept within specific facility departments. ACT+10 years MS-MED-55-10 Facility/Department Records Infection 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. Minimum Standards for Hospitals 1402.3 CY+5 years MS-MED-55-12 Facility/Department Records Respiratory Protection Program Records related to Respiratory Protection Programs. 1 year After Termination or Expiration of License MS-MED-55-14 Facility/Department Records Training and Education Records ACT+3 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 18 of 31
  19. 19. Record Series Code Record Series Title & Description Legal Citation Total Retention Records related to training and certification of employees, which does not include radiological, diagnostic imaging, nuclear medicine training, or nursing. MS-MED-55-16 Facility/Department Records Immunohematology – Quality Control Records Records related to the quality control of immunohematology sample processing and testing to assure that the samples were tested in the same exact manner as the regular patient samples. 21 CFR 606.160; 42 CFR 493.1221 5 years MS-MED-55-18 Facility/Department Records Laboratory – Quality Control Records Records related to the quality control of laboratory sample processing and testing to assure that the samples were tested in the same exact manner as the regular patient samples. 42 CFR 493.1221 2 years MS-MED-55-20 Facility/Department Records Chart Audits Internal audits and related work-papers performed on patient charts. 1 year MS-MED-55-22 Facility/Department Records Intensive Care Unit Logs Log created and maintained by the Intensive Care Unit of a facility. 10 years MS-MED-55-24 Facility/Department Records Implant Logs Implant logs listing items implanted into patients during surgical procedures. 10 years MS-MED-55-26 Facility/Department Records Delivery 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. Minimum Standards for Hospitals 904.15 10 years MS-MED-55-28 Facility/Department Records Operating Room Schedules Schedules of procedures performed in an operating room. 3 years MS-MED-55-30 Facility/Department Records NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 19 of 31
  20. 20. Record Series Code Record Series Title & Description Legal Citation Total Retention X-Ray Logs X-ray logs include name of patient, type of examination, date of the exam, and technician performing the service. 10 years MS-MED-55-32 Facility/Department Records Ambulance Records Records related to the use of an ambulance in transporting patients. MS Code § 41-59- 41 2 years MS-MED-55-34 Facility/Department Records Air Ambulance Safety Committee Meeting Minutes Records detailing the proceedings of the Air Ambulance Safety Committee. CY+ 3 years MS-MED-55-36 Facility/Department Records Emergency Communications Records related to emergency communications received by a facility. Includes audio recordings and call logs. MS Code § 41-59- 41 2 years MS-MED-55-38 Facility/Department Records Special Procedures Unit Logs Records related to endoscopies and outpatient surgeries. Includes patient arrival and departure time and is documented in the patient’s health file. CY+3 years MS-MED-58-02 Medical Research Records Research Papers – Published Published papers from medical staff. Permanent MS-MED-58-04 Medical Research Records Human Experimentation Records Records related to experimental drugs and devices. 30 years Beyond Experiment, Patient Medical Records Should be Retained for Same Period MS-MED-58-06 Medical Research Records Research Reports Reports related to medical research. 10 years MS-MED-60-02 Health Records Patient Medical Records – Adults MS Code § 41-9- 69 (1) Adults of Sound Mind 10 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 20 of 31
  21. 21. Record Series Code Record Series Title & Description Legal Citation Total Retention Complete health records for adult patients. After Discharge, Patients Discharged at Death 7 years MS-MED-60-04 Health Records Patient Medical Records – Minors Complete health records for minors. MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-60-05A Health Records Psychiatric Records-Adults Psychiatric evaluations and treatment provided to patients. MS Code § 41-9- 69 (1) Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-60-05B Health Records Psychiatric Records-Minors Psychiatric evaluations and treatment provided to patients. MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-60-06 Health Records Diagnostic Images Diagnostic images such as x-rays. Interpretations of films are found in the Patient Medical Record. Films may cover any disease or injury and includes mammograms of returning patients. MS Code § 41-9- 69 (2) 4 years After Date of Exposure MS-MED-60-07 Health Records Patient Transfer Records Records related to the patient transfer to and from the hospital. Information is in the Patient Medical Record. 42 USC 1395cc(a) (1)(I) (ii) 5 years From Date of Transfer MS-MED-60-08 Health Records Fetal Heart Monitor Records Records related to fetal heart monitoring. Includes actual strips generated by fetal heart monitors and testing devices. MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 21 of 31
  22. 22. Record Series Code Record Series Title & Description Legal Citation Total Retention MS-MED-60-10 Health Records Disease Index, Operative Index, Physician’s Index, Diagnostic Index, Number Index Health records indexes for disease, operations, and physicians. Minimum Standards for Hospitals 1202.4 Permanent MS-MED-60-12 Health Records Master Patient Index Master index to patient health records. Permanent MS-MED-60-14 Health Records Register of Births Register detailing all births occurring at the facility. Permanent MS-MED-60-16 Health Records Register of Deaths Register detailing all deaths occurring at the facility. Permanent MS-MED-60-18 Health Records Register of Surgical Procedures Register detailing all surgical procedures performed at the facility. Permanent MS-MED-60-19 Health Records Physician 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 MS-MED-60-20 Health Records Emergency Run Reports Reports on patients revived, and/or attempted to be revived, by the administration of drugs, both inter-cardiac and intravenously, and by using counter-shock treatment. Includes all other patients who accepted service from an EMT, EMS or Air-Medical Provider, or a paramedic. MS Code § 41-59- 41 10 years MS-MED-60-21 Health Records Emergency Room Logs Records related to the emergency room. Minimum Standards for Hospitals 701, 705.6 10 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 22 of 31
  23. 23. Record Series Code Record Series Title & Description Legal Citation Total Retention MS-MED-60-22 Health Records Records 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. 10 years MS-MED-60-24 Health Records Records of Tuberculosis Records related to the identification and treatment of tuberculosis, including x-rays, which are not included in the patient’s medical record. 10 years MS-MED-60-26 Health Records Records of Hansen’s Disease Records related to the identification and treatment of Hansen’s Disease, which are not included in the patient’s medical record. 10 years MS-MED-60-28 Health Records Cardiac Catherization Films Films taken before, during, and after a heart catherization procedure. 5 years MS-MED-60-30 Health Records Immunization Record and Consent Form Signed consent forms and records noting the type of immunization performed which are not included in the patient’s medical record. 2 years MS-MED-60-32 Health Records Tumor Registry Files Records related to the identification and treatment of tumors that are not included in the patient’s medical record. MS Code § 41-91- 5 75 Calendar years After Last Entry MS-MED-60-34 Health Records Child Abuse Reports Records related the identification and treatment of child abuse victims. MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-60-36A Health Records Dialysis Records-Adults Records related to dialysis treatments. MS Code § 41-9- 69 (1) Adults of Sound Mind 10 years After Discharge, Patients NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 23 of 31
  24. 24. Record Series Code Record Series Title & Description Legal Citation Total Retention Discharged at Death 7 years MS-MED-60-36B Health Records Dialysis Records-Minors Records related to dialysis treatments. MS Code § 41-9- 69 (1) Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-60-38A Health Records Anesthesia Records-Adults Records related to the administering of anesthesia. MS Code § 41-9- 69 (1); Minimum Standards for Hospitals 2005.3 Adults of Sound Mind 10 years After Discharge, Patients Discharged at Death 7 years MS-MED-60-38B Health Records Anesthesia Records-Minors Records related to the administering of anesthesia. MS Code § 41-9- 69 (1); Minimum Standards for Hospitals 2005.3 Minors – Period of Minority Plus 7 years, But Not to Exceed 28 years MS-MED-60-40 Health Records Autopsy Records Records related to autopsies. MS Code § 41-37- 13 7 years After Autopsy MS-MED-70-02 Nursing Records Staffing Records Daily, weekly, monthly, bimonthly work schedules, and assignment sheets for medical personnel. Includes nursing staff, medical aides, and support staff who provide medical treatment including phlebotomists. Minimum Standards for Hospitals 801.2 CY+6 years MS-MED-70-04 Nursing Records Training Records Records related to nurses training and certification. Minimum Standards for Hospitals 806-807 ACT+3 years MS-MED-70-06 Nursing Records Visit Notes CY+3 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 24 of 31
  25. 25. Record Series Code Record Series Title & Description Legal Citation Total Retention Records consist of observations and notes concerning patients, which are not included in the patient medical record. MS-MED-70-07 Nursing Records Reference Cards Includes duplicate copies of nursing reference notes. AV MS-MED-70-08 Nursing Records Nursing Care Plans Records related to daily care provided by nurses. Minimum Standards for Hospitals 803, 804.2 CY+6 years MS-MED-70-10 Nursing Records Nursing Care Manuals Documentation manuals detailing nursing care procedures. Minimum Standards for Hospitals 802, 803.3 7 years After SUP MS-MED-70-12 Nursing Records Minutes of Meetings Notes or minutes from meeting, includes documented oral conversations and telephone calls pertaining to meeting notes/minutes. Minimum Standards for Hospitals 804.3 CY+3 years; See ADM-90-09 MS-MED-80-02 Pharmacy Records Controlled Substances – Inventory and Orders Records related to the identification and treatment of required inventories and logs pertaining to drugs held by facilities, including pharmacists and EMS units. Includes narcotics. MS Code § 41- 29-133; Minimum Standards for Hospitals 2002.1- 2002.3; Mississippi Pharmacy Regulations XXIII.1; 21 CFR 1304.04 (a) CY+2 years MS-MED-80-03 Pharmacy Records Alcohol (Tax Free) Inventory 27 CFR 22.164 CY+ 3 years From Date of Dispensing MS-MED-80-04 Pharmacy Records Controlled Substances – Dispensed and Administered Records related to the dispensing and administering of controlled MS Code § 41- 29-133; Minimum Standards for CY+2 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 25 of 31
  26. 26. Record Series Code Record Series Title & Description Legal Citation Total Retention substances. Hospitals 2002.1, 2002.2, 2002.4; Mississippi Pharmacy Regulations XXIII.1; 21 CFR 1304.04; 21 CFR 1304.22 MS-MED-80-06 Pharmacy Records Methadone Records Records related to the inventory and administration of methadone. MS Code § 41-29- 133; Minimum Standards for Hospitals 2002.4; 21 CFR 310.505; 21 CFR 291.505 (d)(13)(ii) CY+3 years From Date of Dispensing MS-MED-80-08 Pharmacy Records Prescriptions Records related to written prescriptions maintained by pharmacies. MS Code § 41-29- 133; Minimum Standards for Hospitals 2002.4; 21 CFR 1304.04(h) CY+2 years MS-MED-80-10 Pharmacy Records Patient Profiles Records related to patient profiles maintained by pharmacies. Includes records to whom new and/or refill prescriptions are dispensed. CY+2 years MS-MED-80-12 Pharmacy Records Inspection Reports Pharmacist inspection reports of emergency drug supplies. MS Code § 73-21- 107 CY+2 years MS-MED-80-14 Pharmacy Records Recall Records Minimum Standards for Hospitals 2005.4; Mississippi Pharmacy Regulations XXVI.1 CY+2 years MS-MED-80-16 Pharmacy Records NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 26 of 31
  27. 27. Record Series Code Record Series Title & Description Legal Citation Total Retention Radioactive Drugs Includes inventory and orders of radioactive drugs. Mississippi Pharmacy Regulations XXVII.4 CY+2 years MS-MED-80-18 Pharmacy Records Pharmacy Register Mississippi Pharmacy Regulations XVIII.3.6 CY+2 years MS-MED-90-02 Safety Risk Management Reports Records related to internal risk management. Includes education and training for non-physician employees, analysis of patient grievances, review of incident reports, and minutes of the risk management committee. CY+6 years MS-MED-90-04 Safety Air 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. 1 year After Termination or Expiration of License MS-MED-90-06 Safety Incident Reports Reports of unusual incidents that are recorded by a witness to the incident in a formal manner such as a log, event book, incident form, etc. May be used to report security or injury incidents or to note disturbances in the work place such as fire alarms, roof leak, computer and power outages, car alarms, and other events. CY+6 years After Incident MS-MED-92-02 Waste Disposal Biomedical Waste Records Records related to training, instruction, proper handling, and disposition of biomedical wastes. Minimum Standards for Hospitals 1402.9 II.B.5 CY+3 years MS-MED-92-04 Waste Disposal Biomedical Waste Shipment Logs Records related to the shipment, weight, waste category, location points, and transporter’s receipt of biomedical waste. CY+3 years MS-MED-92-06 Waste Disposal NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 27 of 31
  28. 28. Record Series Code Record Series Title & Description Legal Citation Total Retention Biomedical 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. CY+3 years MS-MED-92-08 Waste Disposal On-site Incineration Records – Acceptance Records Records documenting regulated medical waste to an on-site incinerator for disposal. CY+3 years MS-MED-92-10 Waste Disposal On-site Incineration Records – Operating Logs Records related to the date, length, and total weight of medical waste incinerated per cycle. CY+3 years MS-MED-92-12 Waste Disposal Radioactive 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. 1 year After Termination or Expiration of License MS-MED-92-14 Waste Disposal Radioactive 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. 1 year After Termination or Expiration of License MS-MED-94-02 Engineering Records Emergency Generator Records Records related to the inspection, performance, maintenance, and repairs of emergency generators. Life of Generator Plus 3 years MS-MED-94-04 Engineering Records Air Filter Maintenance Records Records related to the inspection, performance, and maintenance of air filters. Life of Air Filter Plus 3 years MS-MED-94-06 Engineering Records NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 28 of 31
  29. 29. Record Series Code Record Series Title & Description Legal Citation Total Retention Blueprints and Construction Drawings Blueprints and construction drawings detailing the design of company facilities. MS Code § 41-9- 81; Minimum Standards for Hospitals 603.2 ACT+ 6 years; See ADM-40-06 MS-MED-94-08 Engineering Records Construction Project Files Work papers and reports related to specific construction projects. ACT+10 years; See ADM-40-04 MS-MED-94-10 Engineering Records Calibration Records Instrument calibration records performed in accordance with the manufacturer’s instructions. CY+3 years; See MS-MED- 10-16 MS-MED-94-12 Engineering Records Equipment Operating Instructions Records related to manufacturer’s operation instructions. Life of Equipment Plus 3 years MS-MED-94-14 Engineering Records Equipment Inspection and Maintenance Records Records related to equipment inspections and required maintenance. Minimum Standards for Hospitals 1401.4 CY+3 years; See MS-MED- 10-16 MS-MED-94-16 Engineering Records Inspection Reports of Grounds and Buildings Records related to the inspection reports of facility grounds and buildings. MS Code § 41-9- 21; Minimum Standards for Hospitals 1401.4 CY+3 years MS-MED-94-18 Engineering Records Watchman Clock Dials 2 years MS-MED-94-20 Engineering Records Work Orders Work orders related to the inspection, maintenance, and repairs. 2 years MS-MED-94-22 Engineering Records Thermometer Charts CY+3 years MS-MED-94-24 Engineering Records Permits/Licenses Includes heliport, health permits, boiler permits, fire inspection permits, MS Code § 41-9- 81 Retain Until Expiration of Permit or NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 29 of 31
  30. 30. Record Series Code Record Series Title & Description Legal Citation Total Retention FCC license, etc. License Plus 6 years MS-MED-94-26 Engineering Records OSHPD Project Permits and Inspection CY+5 years NOTE: CFR = Code of Federal Regulations, USC = United States Code, MS Code = Mississippi Code, Minimum Standards for Hospitals, Adopted Standards for the Regulation of Medical Waste, Mississippi Pharmacy Regulations, Mississippi Radiological Health Regulations LEGEND: ACT = subject is active, ATX = active plus tax return filing date, CY= current year, SUP = until superseded, TAX = tax return filing date, AV = administrative value Approved: April 20, 2001 Revised: September 10, 2003 30 of 31

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