The Massachusetts Board of Registration in Medicine (BRM) requires maintenance of physician office (patient) records for seven years from the last patient encounter. If a patient is a minor on the date of the last visit, then the physician must maintain the pediatric patient’s records for a minimum period of either seven years from that date, or until the patient reaches the age of 18, whichever is the longer retention period. Interpretations of “the last patient encounter” range from the patient’s last office visit, to the most recent time he or she gave your name as her/his physician.
Records of pediatric and obstetric patients, or those patients who encountered some difficulty during treatment, should be kept for a longer period. Also, if you continue to treat some members of a family, but stopped seeing others, you should retain records for all family members.
Patients may expect their records to be kept “forever.” Although you are not under any legal obligation to do so, you may wish to contact patients you have not seen in seven years and ask if they want you to maintain their records or transfer them to another physician.
When a physician dies, BRM regulations require that his or her estate must retain patient records for a minimum of seven years or until a child patient reaches the age of nine. The successor of a physician who retires is under the same obligation. As a matter of courtesy, patients should be informed by the estate or the successor of the change that has occurred and that they (patients) can obtain their records or have them transferred to a new physician.
Because institutions providing different aspects of health care may be regulated by different agencies, the legal requirements for retention of records may vary. This changes from state to state as well. In Massachusetts, most institutions and clinics (including staff-model HMOs) must retain medical records for 30 years after the discharge or final treatment of the particular patient.
Radiological films, scans, other image records, raw psychological testing data, electronic fetal monitoring tracings, EEG tracings, electrocardiography tracings, and the like, are not considered legal medical records, but must be retained for at least five years from the date of the service. A signed report of the findings based on the data must be maintained in the permanent medical record, and any sample tracings generated as part of the actual report itself must continue to be maintained.
This five-year period for test materials is a minimum, and should be evaluated in the context of possible patient care needs for certain disease entities or patient age groups. When one contemplates the possibility of “look-back” needs, an interim retention period of at least 10 years seems prudent.