URMC Compliance Program Policy Manual:
Record Keeping And Retention

The URMC facilities are obligated under both state and federal law to maintain and retain numerous different types of records concerning nearly every aspect of their operation. Particularly important is the proper maintenance of hospital records concerning patient treatment. Proper record keeping is necessary not only to comply with state and federal law but also to ensure proper medical treatment for patients in the future. Patient records may also be important in the event there is litigation.

New York State Law

In order for a hospital to maintain and renew its hospital license under state law, it must comply with the following applicable record keeping requirements.

State law requires the hospital to maintain records of the diagnosis and treatment of patients, including medical history records and nursing notes, for 6 years after the discharge (or 3 years after a minor patient's 18th birthday, whichever is longer), or 6 years after death.

The Department of Health also requires the hospital to maintain various other records including: hospital surveys; contracts relating to the ownership of land, buildings and equipment; operating procedure manuals; patient complaints; and others enumerated in Department of Health Regulations.

Any questions about the hospital's duty to maintain specific records should be referred to the Compliance Officer or legal counsel.

Federal Law

Federal law also imposes strict record keeping requirements. Failure to comply with these laws and regulations may result in monetary penalties or suspension from participation in federal programs.

The Federal Controlled Substances Act requires certain personnel to prepare biennial inventories of all stocks of drugs and narcotics and maintain continuing current records of the amounts of drugs received and dispensed. 21 U.S.C. ¤¤ 827 (a)(1), (a)(3). Federal regulations also require certain personnel to maintain records and inventories of each substance it dispenses. The retention period for these records is a minimum of two years. [21 CFR 1304.03, 1304.04.]

As a condition of continued participation in Medicare and Medicaid, federal law requires providers to maintain a variety of records, ranging from financial to medical. The principles of cost reimbursement require that providers maintain sufficient financial records and statistical data for proper determination of costs payable under the Medicare and/or Medicaid programs. Providers must maintain such records as are necessary to ascertain information pertinent to the determination of the proper amount of program payments due, including, but not limited to: hospital ownership, organization, and operation; fiscal, medical, and other record keeping systems; federal income tax status, asset acquisition, lease, sale or other action; franchise or management arrangements; patient cost service charge schedules; cost of operation; amounts of income received by source and purpose; and flow of funds and working capital. The required physician certification and re-certification statements must also be maintained.

A hospital must maintain medical records for every patient for a minimum of five years. The individual records must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications. All records must document the following, as appropriate: evidence of a physical examination; admitting diagnosis; results of all consultative evaluations; documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia; properly executed informed consent forms; all doctors' orders, nursing notes, and reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient's condition; discharge summary with provisions for follow-up care; and final diagnosis with completion of medical records within 30 days following discharge. In addition, the hospital must maintain radiologic services records, surgical services records, anesthesia services records, and nuclear medicine records.

Confidentiality

The Medical Center is committed to properly maintaining the required records as well as preserving their confidentiality in accordance with applicable law and the Medical Center's policies. Please consult the Confidentiality section of this Manual for further details.

The Compliance Officer has established a records retention schedule that is available for review. If you have any questions, please contact the Compliance Officer.