AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 6547
TITLE: Patient case files
DATES: 1994.
ARRANGEMENT: Chronological, thereunder numerical by patient number

DESCRIPTION: These are the medical files for all Pioneer Care Center patients. They are used to document all treatment and care received by patients while admitted to the care center. These files include consent forms, substance records, physicians orders, medication records, nurses notes, and related correspondence. Four times a year files are weeded and less important forms are pulled and placed in storage files called "thinned files." At the patient's discharge or death these files are incorporated into the main files.

RETENTION

DISPOSITION

RETENTION AND DISPOSITION AUTHORIZATION

Retention and disposition for this series were specifically approved by the State Records Committee.

APPROVED: 03/1991

FORMAT MANAGEMENT

Paper: Retain in Office for 7 years after discharge or death of patient and then destroy.

APPRAISAL

Administrative Legal

This disposition is based on both the records administrative needs expressed by center's administrator and the legal requirements. 42 Code of Federal Regulations (CFR) 483.75 (1990) provides that "clinical records must be retained for (i) The period of time required by state law; or (ii) Five years from the date of discharge when there is no requirement in State law." The state of Utah does not have a specific medical records statute. Utah Code Annotated (UCA) 78-14-4 (1990) provides that "No malpractice action brought against a health care provider may be brought unless it is commenced within two years after the plaintiff or patient discovers, or through the use of reasonable diligence should have discovered the injury, whichever first occurs, but not to exceed four years after the date of the alleged act." The care center has requested the records be maintained for seven years to meet all administrative needs and legal concerns.

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