Discard old clinical records?
State laws determine how long you need to keep clinical records.
Don't discard lab reports or X-rays until the statute of limitations has expired.
An old X-ray or lab report could bolster your defense.
Q:To prevent medical records from getting too thick, I'm considering putting a flow sheet on the inside front cover of patient charts, where I'd write the results of lab work and imaging studies. Can I then discard the original lab work, X-rays, and radiology reports? After all, the lab and radiology center will always have the originals available if I ever need them.
A: Don't do it right away. You should retain all your records until you're clear of any potential lawsuitsespecially those that allege failure to diagnose. If you're sued for that reason, you'll want to be able to produce any lab and imaging reports that support your diagnosis. Do you really want to rely on a lab or radiology service for that defense? What if the service lost the report or X-rays? What if it went out of business? What if a fire or flood destroyed the reports?
Also, consider the possibility that your interests may differ from those of the lab or radiology service. They could be named as co-defendants, and may even claim that their report reached the correct diagnosis, but you mishandled it. Or, conversely, suppose the report missed the correct diagnosis. Your best defense will be that you reasonably relied on the findings of their experts and therefore met the standard of care. Since the report would be damaging to the lab or radiology service, it might understandably be reluctant to turn over the report.
It's wise, then, to retain all records until the statute of limitations has expired. That's the amount of time that may elapse between the alleged malpractice and the filing of a lawsuit. In most states, the statute of limitations is two or three years. For obstetrical or pediatric cases, though, it can extend until the juvenile reaches the age of majority plus two to three years.
Your state law may also require you to keep all pertinent records during the statute of limitations. That requirement might be hard to pin down, though, since the laws aren't always specific. Regulations usually say something vague like, "you must retain all records necessary to support the diagnosis and treatment." So it makes sense to play it safe by keeping reports on lab work and imaging studies.
Once the statute of limitations has passed, then paring down your files is a good idea to get a handle on voluminous records. And a flow sheet that lists the documents that aren't contained in the chart is a good technique for keeping track. Other documents can be microfilmed, microfiched, or even summarized. When you do dispose of your old records, don't throw them in the trash. Shred them, or hire a company with expertise in this area. And ask for proof that the records have been destroyed. (For more on disposing of medical records, see "Do you need a paper shredder?" in the Nov. 8, 2002 issue.)
Another way to trim patient charts is by scanning into your computer such financial records as EOBs and photocopies of insurance checks. Probably the most effective way to streamline files is by using an electronic medical record. Some even allow you to import clinical data directly from labs and imaging centers. To find out whether an EMR makes sense for your practice, see "EMRs: What you need to know" in the May 9, 2003 issue.
Lee Johnson. Malpractice Consult: Discard old clinical records?.
Jul. 25, 2003;80:76.