Section 340.1830  Retention, Transfer, and Inspection of Records

a)         Each facility shall have a policy regarding the retirement and destruction of medical records.  This policy shall specify the time frame for retiring a resident's medical record, and the method to be used for record destruction at the end of the record retention period.

b)         Records of discharged residents shall be placed in an inactive file and retained as follows:

1)         Records for any resident who is discharged prior to being 18 years old shall be retained at least until the resident reaches the age of 23.

2)         Records of residents who are over 18 years old at the time of discharge shall be retained for a minimum of five years.

3)         After the death of a resident, the resident's record shall be retained for a minimum of five years.

4)         It is suggested that the administrator check with legal counsel regarding the advisability of retaining resident records for a longer period of time.

5)         If a facility ceases operation, procedures for handling resident records shall be developed by legal counsel.

c)         When a resident is transferred to another facility, the transferring facility shall send with the resident a reason for transfer, summary of treatment and results, laboratory findings, and orders for the immediate care of the resident.  This information may be presented in a transfer form or an abstract of the resident's medical record.

d)         The facility shall retain other records required by these standards for a minimum of three years.  Procedures to be followed in the event the facility ceases operation shall be developed by facility legal counsel.

e)         Each resident record is the property of the facility.  The facility shall be responsible for securing resident record information against loss, defacement, tampering or use by unauthorized persons.

f)         Every resident, resident's guardian, or parent (if the resident is a minor) shall be permitted to inspect and copy all of the resident's clinical and other records concerning the resident's care and maintenance kept by the facility or by the resident's physician.  (Section 2-104(d) of the Act)