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Medical Records:Making and Retaining Them

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Medical Records:Making and Retaining Them

文章来源：医学全在线更新时间：2007-7-15 1:32:48 考研论坛

Medical Defence Union. Medical Records. In: Issues in Medical Defence No. 1, 1993:33 -35

Medical Protection Society. Making and keeping medical records. MPS Casebook. Jul 2000:6-8

http://www.mps.org.uk

Ministry of Health, Singapore. Retention Periods for Medical Records – Meeting Legal Requirements.

Circulars No. 1/96 and 3/96.

United Medical Protection. Regulations and Medical Records. United Medical Protection Journal Issue 1,

1999: 14

United Medical Protection. Correcting the Medical Record. Professional Development – downloaded from

United Medical Protection website on 22 November 2000. http://www.unitedmp.com.au

ANNEX 1 - REVISED RETENTION PERIODS FOR MEDICAL RECORDS

(1 FEBRUARY 1996)

Type of Medical Records

Retention Period /1

Remarks

Primary Medical Records /2

Secondary Medical Records /3

(A) HOSPITAL RECORDS
(i)                   Adult Medical
·                      Inpatient
·                      Specialist Outpatient

(ii)                 Adult Surgical
·                      Inpatient
·                      Specialist Outpatient

(iii)                Paediatric Medical
·                      Inpatient
·                      Specialist Outpatient

(iv)                Paediatric Surgical
·                      Inpatient
·                      Specialist Outpatient

(v)                 Cancer Records
·                      Inpatient
·                      Specialist Outpatient

(vi) Psychiatric Records
· Inpatient

· Specialist Outpatient

(vii)              Accident & Emergency Records
·                      Accident/Police cases
·                      Medical cases

(B) PRIMARY HEALTH CARE (PHC) RECORDS
· Outpatient records
· School Health Records

(D) PATIENT REGISTERS
(Eg. Admission Register, Outpatient Attendances Register, A&E Attendance Register, Operation Record Book, X-ray Register, Ward Register, etc)

(E) COMPUTERISED PATIENT RECORDS / DATABASES

3 years
3 years

5 years
5 years

till death
till death

7 years after death of patient
7 years after death of patient

5 years
3 years

5 years*
3 years

3 years

Indefinitely

17 years
17 years

indefinitely
indefinitely

NA
NA

NA
Up to age 21 years

] Exception:
] Where hospital is aware that legal ] action has been initiated, complete ] medical records of patient should
] be retained until completion of
] legal proceedings.
]
] Hospital to stamp “Medico-Legal ] case” prominently on the case
] folder of these cases.
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
Hospital A&E Departments to
highlight all accident/police cases
records by stamping
“Accident/Police Case”
prominently on all the records.

] Exception above regarding
] retention of complete records of
] patient for Medico- Legal case
] also applies to PHC and Dental
] records.
]
]

3-year retention period applies to paper records, including their computer-generated hard copies.

./1 ]

/2 ] Please see explanatory notes attached

/3 ]

- Records to be retained for 3 years at the clinic and a further 2 years at another location

/RE312(RETENTN.DOC) [source: MOH circular 1/96]

NOTES:

1. Retention Period

Retention period refers to the period following the date of last discharge from hospital or last attendance at the Outpatient Clinic.

2. Primary Medical Records

2.1 Primary Medical Records refer to all the original inpatient and outpatient records generated at the time of admission or outpatient attendance.

2.2 After the specified period of retention, primary records must be culled by extracting the forms listed in para 3 below, which will be assembled to form the Secondary Medical Records

3. Secondary Medical Records

Secondary Medical Records include the following documents of patients:

· Inpatient / Outpatient Discharge Summary

· Operation Report Form

· Consent for Operation Form

· X-ray Report Form

· Histopathology Investigation and Report Form

· Maternity Record Form

· Labour Record Form

· Neonatal records which are enclosed in the mother’s casenotes

· Workmen’s Compensation Reports, Insurance, Medical and other Medico-Legal Reports

4. Microfilmed Records

Original paper secondary medical records of patients which have been microfilmed may be destroyed. Before destruction of the original documents, hospitals/institutions must first ensure that the microfilmed records are properly kept and that the microfilms are clearly catalogued for easy retrieval.

Minimum retention period for microfilmed secondary records of patients is 17 years.

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