Tossing copies of results?

October 6, 2006

Do we have to keep copies of physician-ordered studies, like pathology and X-ray reports, in patient charts? Can't we just note the results in the chart, discard the paperwork, and then, if we need the copies later, just request them from the office that performed the test?

Q:Do we have to keep copies of physician-ordered studies, like pathology and X-ray reports, in patient charts? Can't we just note the results in the chart, discard the paperwork, and then, if we need the copies later, just request them from the office that performed the test?

A: No. The patient and her insurer have a right to the complete chart containing all the original entries and lab results, and you should be able to provide it promptly.

Moreover, it's always a bad idea to destroy test results-even with a backup plan to obtain copies from the original provider, if necessary. In case of a lawsuit, it could look as if you had tried to destroy evidence, in which case the judge could instruct the jury to assume that you were trying to hide something.