Hospitals and Clinics
Analytic System Records, Test Procedures - Anatomical Pathology
These records consist of results on printouts, reports, quality control or PDF files for specimens tested each day, manual result logs, handwritten reports or downtime patient testing forms. These records are checked for accuracy against the results in the computer system and each record. These records are retained for accreditation, audit and administrative purposes.
Analytic System Records, Test Procedures - Clinical Pathology General Laboratory
These records consist of results on printouts, reports, quality control or PDF files for specimens tested each day, manual result logs, handwritten reports or downtime patient testing forms. These records are checked for accuracy against the results in the computer system and each record. These records are retained for accreditation, audit and administrative purposes. This retention does not apply to Transfusion Services.
Anatomical Gifts (Body Donations)
These records document the anatomical gift of a human body, to take effect after the donor's death, for the purpose of research or education. Records may include body donation files, applications, forms, the dates bodies are out for dissection, brief medical histories, information on unclaimed bodies, morgue records, cremation records, etc.
Clinical Pathology Peripheral Blood Smears/Body Fluid Smears and Permanently Stained Microbiology Slides
These records are slides, smears or paraffin blocks made from patient specimens for immediate diagnosis and research purposes.
Cost Reports for Medicare, Medicaid and Tricare
Cost reports are filed annually with Medicare, Medicaid and Tricare. The files include copies of the original filed cost report, supporting documentation used to complete the cost report, all audit correspondence and adjustments, copies of the Notice of Program Reimbursement (NPR), and any appeal or litigation correspondence. Also, included are other supporting records maintained by Accounting, Payroll, and Patient Finance.
Daily Processes, Reports, Logs and Archival Data for Anatomical and Clinical Pathology
These records consist of reports generated daily by individual laboratories and reference laboratories, listing critical information to be reviewed by senior departmental staff or results that are placed in patient charts. These reports are to be retained for accreditation, audit and administration purposes. They may include, but are not limited to Daily Processes Reports, Competency and Proficiency Reports, Discontinued Procedure Reports, Quality Control Reports, Archival Data Disks from Automated Analyzers, and Reference Reports. In addition, these records consist of electronic and manually produced log sheets documenting the receipt of specimens for testing. This retention does not apply to Transfusion Services.
Dermatology Blocks
These records are paraffin blocks made from dermatology patient specimens submitted for immediate diagnosis and research purposes. Blocks include epidermis, dermis and subcutaneous tissue, and lymph nodes for the removal or diagnosis of skin conditions and lesions.
Dermatopathology Glass Specimen Slides
These are records of glass slides that contain dermatology patient specimens submitted for immediate diagnosis and research purposes. Glass specimen slides include H&E-stained slides, positive/ negative immunohistochemistry slides, special stained slides, control slides and MOHS surgical slides.
Equipment Maintenance and Repair Records for Anatomical and Clinical Pathology
These records consist of documentation of scheduled and unscheduled equipment and instrument maintenance and repairs. This retention does not apply to Transfusion Services.
Fluids and Tissues - General Laboratory - Peripheral Blood/CSF/Body Fluids (Except Urine)
These records are samples of wet tissues (stock or otherwise), or fluids, submitted as patient specimens for testing, immediate diagnosis, and research purposes.
Fluids and Tissues - General Laboratory - Urine
These records are samples of urine submitted as patient specimens for testing, immediate diagnosis, and research purposes.
Fluids and Tissues - Microbiology (Blood Cultures)
These records are samples of wet tissues (stock or otherwise), or fluids, submitted as patient specimens for testing, immediate diagnosis, and research purposes.
Fluids and Tissues - Molecular Pathology (DNA Samples)
These records are samples of wet tissues (stock or otherwise), or fluids, submitted as patient specimens for testing, immediate diagnosis, and research purposes.
Fluids and Tissues - Surgical Pathology Foreign Bodies
These records are samples of surgical foreign bodies submitted as patient specimens for testing, immediate diagnosis, and research purposes.
Fluids and Tissues - Surgical Pathology Wet Tissues
These records are samples of wet tissues (stock or otherwise), or fluids, submitted as patient specimens for testing, immediate diagnosis, and research purposes.
Forensic Autopsy Fluids and Tissues - Wet Stock Tissue, Body Fluids, and Tissues for Toxicology
These records are samples of wet tissues (stock or otherwise), or fluids, submitted as patient specimens for testing, immediate diagnosis, and research purposes.
Forensic Autopsy Paraffin Blocks, Glass Specimen Slides, DNA Samples
These records are slides or paraffin blocks, DNA samples made from patient remains that were submitted for forensic autopsy.
Forensic Autopsy Specimen Receipt Logs and Autopsy Reports
These records consist of log sheets on which personnel of various laboratories document receipt of forensic autopsy specimens sent for examination and autopsy reports.
Glass Specimen Slides and Paraffin Blocks
These records are slides or paraffin blocks made from patient specimens for immediate diagnosis and research purposes. This category includes anatomical pathology, surgical, cytology and non-forensic autopsy slides and blocks. Glass specimen slides and blocks include negative or unsatisfactory slides, positive or suspicious slides, fine needle aspiration slides, and surgical pathology including bone marrows.
HIPAA Compliance Documentation
Documentation indicating the actions taken to comply with HIPAA privacy and security rules. This may include policies and procedures, copies of communications, and all activities, actions, or designations that require records including business associate agreements.
Hospital Census Data
The hospital census is an official count of patients admitted to a facility by midnight, or another designated time of the day or evening. These records are used to calculate average inpatient stays and the number of patients in facilities.
Images, Photographs, Plots and Histograms - FISH
These records are FISH assays created from specimens submitted for testing, analysis, and diagnosis.
Images, Photographs, Plots and Histograms - Flow Cytometry
These records are gated dot plots and histograms created from specimens submitted for testing, analysis, and diagnosis.
Images, Photographs, Plots or Histograms - Gross Photographs/Negatives
These records are photographs, images, plots or histograms created from specimens submitted for testing, analysis, and diagnosis.
Non-Forensic Autopsy Fluids and Tissues- Wet Tissue
These records are samples of wet tissues (stock or otherwise), or fluids, submitted as patient specimens for testing, immediate diagnosis, and research purposes.
Non-Forensic Samples for DNA Analysis
These records are processed or stock samples of wet tissues or fluids, submitted as patient specimens for testing, immediate diagnosis, and research purposes.
Patient Billing and Payment Records
These records document the general billing for treatment or services received and associated payments for all hospital and clinic services. These records include payments made by the patient, insurance company, Medicare, Medicaid, Third -Party Payer Remittance, and any other payors. These records include Remittance Advices, Explanations of Benefits, Cash Receipt Reports, Submitted Claims and Supporting Documentation.
Patient Treatment Records (Electronic Only)
This records series applies to electronic documentation in patient charts related to tests, treatments, and hospitalizations of all patients treated or for services performed at University Hospital and Clinics departments for adults, minors, students and deceased patients. This retention also applies to the Schools of Psychology, Orthodontics, Ophthalmology, Dentistry, Vision, etc.
Patient Treatment Records (Paper and Microform Only)
This retention applies to hardcopy (paper and microform) patient treatment records and charts. This retention applies to adults, minors, students and deceased patients with paper or microfilm treatment files or charts created prior to the implementation of electronic patient charts in 2017. This retention also applies to dental, vision, behavioral health, anesthesia, fetal monitoring strips, newborn nursery log books, cardiac rehabilitation and care, death charts, and kidney care records/charts stored in paper form. This retention does not apply to electronic patient records. See Patient Treatment Records (Electronic).
Prescriptions, Refills and Controlled Drug Records
Records of prescriptions written by physicians for patients to obtain medications. Also includes records of refills, controlled drug records, and other records tracking the distribution and dispensing of prescription drugs.
Quality Assurance/Control Records
These records consist of various documentation maintained by hospital departments to verify and monitor the quality of their services, equipment, and other activities of their departments.
Registrations and Requisitions Anatomical and Clinical Pathology
These files consist of forms initiated by hospital/clinic personnel; either for registration or for requesting testing on specimens collected from patients. Test results are also provided in the patient’s medical chart. This retention does not apply to Transfusion Services.
Specimen Receipt Log Sheets for Anatomic Pathology and General Laboratory
These records consist of log sheets which personnel of various laboratories document receipt of specimens sent for examination. Examples include Central Processing, PKU logs, and cord blood testing availability.
Speech and Hearing Clinic Files
These records document the patients and treatment (adult, children and infants) and/or clients treated in the Speech and Hearing Clinic. These records are retained to certify hours of speech and language therapy provided by students while pursuing their degree and are required for future employment.
Transfusion Services - Blood Supplier Invoices and Transfer Sheets
These records consist of invoices received from suppliers of blood products for Transfusion Services, with attached shipping and transfer sheets from products received.
Transfusion Services - Equipment Maintenance, Archival Data, Repair and Validation
This series includes equipment validation, maintenance, archival data, and repair records. These records will consist of package inserts (with obsolete revisions) supplied by the manufacturer for reagents used by Transfusion Services. These records also include documentation of scheduled and unscheduled equipment and instrument maintenance. These records consist of computer disks containing patient, quality control, or other data archived from automated analyzers.
Transfusion Services - General Transfusion Records
This series of records includes reference reports, antibody identification panels, deviations from standard operating procedures, transfusion quality control, blood product final disposition records, compatibility cards, emergency release forms, lookback reports, reagent/critical material records, and records of laboratory employee names, signatures, initial and identification codes.
Transfusion Services - Requisitions, Registrations, and Quality Assurance
These transfusion records consist of forms initiated in the hospital computer system or handwritten by hospital personnel; either for registration or for requesting testing on specimens collected from patients. Requisitions may indicate patient name and medical record number, type of specimen submitted for examination, and type of test to be performed. Completed results of these tests are entered into the patient's medical chart through the computer system. If requisitions are scanned into the medical record, paper forms need not be retained. In addition, these records include management review of the effectiveness of the quality system, proficiency and competency records, and discontinued policies and procedures.
Transfusion Services - Serum/Heparinized or EDTA Plasma and Red Cells
These records are samples of wet tissues (stock or otherwise), or fluids, submitted as patient specimens for testing, immediate diagnosis and research purposes.
Transfusion Services - Special Transfusion Requirements
The following special event transfusion records must be retained indefinitely: records indicating difficulty in blood typing, clinically significant antibodies, significant adverse events to transfusion, and special transfusion requirements.
X-Rays/Films
This series applies to original x-ray films (such as emulsion of silver halide) that result in reports/interpretations placed in patient charts. The original film should be recycled in a way that preserves the confidentiality of the information. The results/interpretations are placed in the patient's chart and are retained as part of the patient file for the required retention period.