Retention of medical records

Medical Records

Adopted: Sun, 2010-09-26 - Modified: Tue, 2010-11-16

Back to Position Statements

Reviewed: 2014-11-13 - no changes

Podiatrists have both a legal and ethical obligation to retain patient records. The Board, therefore, recognizes the necessity and importance of a licensee's proper maintenance, retention, and disposition of medical records. The following guidelines are offered to assist licensees in meeting their ethical and legal obligations:

• State and federal laws require that records be kept for a minimum length of time including but not limited to:
  1. Medicare and Medicaid Investigations (up to 7 years);
  2. HIPAA (up to 6 years);
  3. Medical Malpractice (varies depending on the case but should be measured from the date of the last professional contact with the patient)-podiatrists should check with their medical malpractice insurer);
  4. North Carolina has no statute relating specifically to the retention of medical records;
  5. Podiatry-appropriate immunization records always must be kept.
• In addition to existing state and federal laws, medical considerations may also provide the basis for deciding how long to retain medical records.
• In deciding whether to keep certain parts of the record, an appropriate criterion is whether a podiatrist would want the information if he or she were seeing the patient for the first time. The Board, therefore, recognizes that the retention policies of podiatrists giving one-time, brief episodic care may differ from those of podiatrists providing continuing care for patients.
• In order to preserve confidentiality when discarding old records, all records should be destroyed, including both paper and electronic medical records.
• Those licensees providing episodic care should attempt to provide a copy of the patient's record to the patient, the patient's primary care provider, or, if applicable, the referring podiatrist.
• If it is feasible, patients should be given an opportunity to claim the records or have them sent to another podiatrist before old records are discarded.
• The podiatrist should respond in a timely manner to requests from patients for copies of their medical records or to access to their medical records.
• Podiatrists should notify patients of the amount, and under what circumstances, the podiatrist will charge for copies of a patient's medical record, keeping in mind that N.C. Gen. Stat. 90-411 provides limits on the fee a podiatrist can charge for copying of medical records.

*Podiatrists should retain medical records as long as needed not only to serve and protect patients, but also to protect themselves against adverse actions. The times stated may fall below the community standard for retention in their communities and practice settings and for the specific needs. Podiatrists are encouraged (may want to) seek advice from private counsel and/or their malpractice insurance carrier.