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Retention Schedules


November 2005   

Hospital and Health District Records Retention Schedule

See also the General Records Retention Schedule.

Using this Records Retention Schedule

Everyday local government offices throughout Missouri produce records that document the rights of citizens, the actions of the government that serves them and the history of the community in which they live. It is the responsibility of local government to effectively maintain and manage these records and to ensure the continued preservation of those records of essential evidence that have enduring and permanent value.

The introduction to this retention schedule provides local government officials with basic information on records and the application of retention schedules.


What is a Record?
A " record " is defined as any "document, book, paper, photograph, map, sound recording or other material, regardless of physical form or characteristics, made or received pursuant to law or in connection with the transaction of official business" (109.210(5) RSMo). This definition includes those records created, used and maintained in electronic form.


Non-Records
Even though records include a broad spectrum of recorded information, not all recorded information is a record. According to Section 109.210(5) RSMo, the following are not records: "...Library and museum material made or acquired and preserved solely for reference or exhibition purposes, extra copies of documents preserved only for convenience of reference, and stocks of publications and of processed documents are not included within the definition of records..."

Other examples of non-records include the following materials:

Non-records do not require retention scheduling or destruction authorization or reporting. To control excessive accumulation, it is necessary to keep only current, useful materials and to destroy non-records immediately after needs have been satisfied. Avoid filing non-record material with records.


The Value of Local Government Records
Some records, because of their enduring administrative, fiscal, legal or historical value, should be permanently retained. These records require that special care and consideration be given to their storage conditions and the feasibility of preservation microfilming. Examples of permanent records include year-end reports; minutes; property records such as deeds; and birth, death and marriage records.

Most records do not have values that warrant their permanent preservation. Those records with short-term value should, upon reaching end of the retention period, be destroyed.


Statutory Authority for Establishing Records Retention Requirements
In 1965, the Missouri General Assembly established a State Records Commission to approve retentions for records produced by state agencies. In 1972, Missouri's Business and Public Records Law (Chapter 109) was expanded to include local government. Thus, the Missouri Local Records Board was established to set retention times for local government records. The 16-member board, chaired by the Secretary of State, consists of local government officials from all classes of counties and cities, elementary and secondary education, higher education and a person active in historical society groups.

Supplemental to the Local Records Board, the Records Management and Archives Service of the Secretary of State's office provides assistance to local governments and implements board policy.


Application of the Records Retention Schedule
This schedule establishes minimum retention periods and authorizes dispositions for many of the administrative, fiscal and legal records common to most local governments. Retention periods are based upon federal and state mandates, record surveys, business needs, and general knowledge as to how long records should be kept. Using the schedule as a guide and without seeking further approval from the Local Records Board, any local government may regularly dispose of any of its records that appear on this schedule. The schedule is subject to the following exceptions and limitations:

  1. Local government offices may retain any of their records beyond the retention periods set by the schedule, as they deem necessary. The schedule establishes only a minimum period of retention. Before retaining a record longer than the minimum time required, however, the office should be certain that it has good reason to do so. Unnecessary retention of records can be expensive in space and filing equipment and may expose the office to costly litigation and discovery requirements.
  2. This schedule does not relieve local governments of retention requirements mandated by other state and federal statutes and regulations. When such an obligation does exist, then the longer retention period takes precedence.
  3. This schedule generally reflects audit requirements in its prescribed retention periods, but audits are not always completed in a timely fashion. Therefore, any record required for an audit must be retained until completion of that audit, regardless of its stated retention period in the schedule.
  4. This schedule does not authorize destruction of records that could be deemed relevant to current or pending litigation.

Retention and disposition of records that are common to many offices are included in the General Schedule. Records unique to particular offices are addressed in individual office schedules. All schedules are available on the Secretary of State's website at http://www.sos.mo.gov/archives/localrecs/schedules .


Destruction of Records
The records classification and retention periods in this manual constitute legal authority for retention and disposal of official records. No records can be destroyed until they meet the minimum retention period listed in this manual. In cases where there is no schedule for a particular record series, the Local Records Board must grant permission for the destruction.

The disposition of records should be recorded in a document such as the minutes of the city council or other legally constituted authority that has permanent record status. The record should include the description and quantity of each record series disposed of, manner of destruction, inclusive dates covered and the date on which destruction was accomplished.

The retention schedule does not prescribe the method of destruction (shredding, burning, landfills, etc.), however, record series with a disposition of Destroy securely contain confidential data. These records should be destroyed under the supervision of a competent person(s) designated (or appointed) to ensure that no records fall into unauthorized hands and that the data cannot be reconstructed.


Preservation of Permanent Records
A fundamental, yet often neglected obligation of local government is to care for its permanent records-in this case, some of the records that it generates and receives. The records that have been identified as permanent require special handling and storage if they are to be preserved. The continuous interaction between a record's medium-paper, magnetic tape, film, etc. -and the quality of the environment in which it is kept-temperature, humidity, light, and air-determines the severity and rate of its deterioration.

By microfilming older, deteriorating, but permanently valuable records, local governments can generate durable copies for research and prevent further damage or deterioration of the original. When filmed, processed, and maintained to archival specifications, the master negative will ensure that permanently valuable records are preserved for generations to come.

The Missouri Local Records Grant program can provide financial assistance in the form of grants-in-aid to supplement local funds for preservation initiatives, such as archival supplies, shelving and preservation microfilming.


A Note about Electronic Records
Permanent records existing solely in electronic form are in danger of becoming inaccessible through media decay and hardware/software obsolescence.  Periodic migration and transfer of permanent records to stable preservation media, such as microfilm, should be considered as a best practice for local government to fulfill its statutory responsibility to maintain permanent records.


Modifications and Additions
Because records reflect activities that are constantly changing, the retention requirements for them sometimes require revision as well. Consequently, records retention and disposition schedules often need modification or additions in order to be realistic and effective. Furthermore, because local governments are so large, it is impractical to consult with every office regarding specific schedule entries. There may be some retention periods and disposition requirements within this schedule that fail to account for all relevant factors and there may be some important record series not addressed here which need to be added. The Local Records Program welcomes all comments and suggestions concerned with improvement of record retention schedules through modifications and additions.

For further information on any records management or preservation issue, please contact:

Missouri Secretary of State
Local Records Preservation Program
PO Box 1747, Jefferson City, MO 65101-1747
Telephone: (573) 751-9047
Fax: (573) 526-3867

Hospital and Health District Records Retention Schedule

See also the General Records Retention Schedule.

Record Series Title Retention

Accounting Department

Authorized Signature Cards

Completion of audit

Balance Sheets

Completion of audit

Capital Assets Ledger

Completion of audit

Cost Allocation Reports

Completion of audit

Credit Memos

Completion of audit

Debit Memos

Completion of audit

Depreciation Schedules

Completion of audit

Expense Records

Completion of audit

Operating Statements

Completion of audit

Property Account Ledgers

Completion of audit

Social Security Reports

Completion of audit

Statistical Analysis of Budget Expense

Completion of audit

Administration

Administrative Manual

Permanent until updated

Affiliation Agreements

Term of Agreement Plus Audit

Application for Registration Under Controlled Substances Act

Permanent

Facility Inspection Reports (Motel, Food Service, Etc.)

Permanent

Financial Statistics

Destroy in current area

Free Alcohol Permits (Tax Exempt Certificates)

Permanent

Hospital Rate Book

Permanent until updated

Incident Reports--Patients and Visitors

10 years

Monthly Missouri High Risk Maternal and Child Care Reports

1 year

Organizational Dues

1 year

Patient Questionnaires
(Applications For County Health Care Services; May Include Personal Financial Statements)

Destroy in current area

Personnel Statistics

Destroy in current area

(Record of Applications and Reappointment, License Verifications Privileges, Physicians' Staff Alternate List, Call Numbers, Emergency Room Call Roster, Physicians' Staff Officers and Committees, Staff Status List, Correspondence, Memos, and Prospective Phusicians)

Permanent until updated

Scholarship Files

Discretion of the Hospital

Surveys

Destroy in current area

Transfer Agreements

Permanent

Tribute Fund:
(Name of Those in Memory of, Names of People Acknowledged, Name of Donors, Amount Donated)

Permanent

Admissions

Admission Charge Tickets

Completion of audit

Admission Log Book

Permanent

Guarantor Book

Completion of audit

Hospital Admission Forms Copy:

See Footnote #2

Hospital Admission Forms Original:

Permanent

Anesthesia

Daily Log (Date, Patient's Name, Hospital Number, Charge Code, Time, Complications)

See Footnote #1

Monthly Culture of Equipment For Infection Control

See Footnote #1

Autopsy

Autopsy Report

See Footnote #1

Permission For Autopsy

See Footnote #1

Business Office

Hospital Price Manual

Permanent until updated

Outpatient Clinic Appointment Books

See Footnote #1

Outpatient Logs

Completion of audit

Outpatient Medicare Signatures

Completion of audit

Data Processing

Computer Schedules

Permanent until updated

Data Processing Reports (Accounts Receivable and Payable; Inpatient, outpatient, and bad debts reports)

Completion of audit

Federally-Regulated Records

Medicaid Records

Federal Regulations

Medicare Records

Federal Regulations

WIC (Women, Infant, & Children's) Program

Federal Regulations

Food Services

Charts On Diabetics

Permanent

Daily Census of Number Of Visitors Through Cafeteria Line

3 months

Daily Census of Number Of Employee Through Cafeteria Line

3 months

Daily Census of Patient Trays

1 year

Daily Record of Dietary Time Card Edits Copy:

See Footnote #2

Daily Record of Dietary Time Card Edits Original:

Completion of audit

Daily Record of Salary For Each Employee Copy:

See Footnote #2

Daily Record of Salary For Each Employee

Completion of audit

Daily Record of Absent Report Form Copy:

See Footnote #2

Daily Record of Absent Report Form Original:

Term of Employment Plus 3 Years

Daily Record of Dietary Benefit Listings

Destroy in current area

Daily Record of All Equipment (Parts and Maintenance)

Permanent until updated

Daily Record of Vacation and Sick Leave Copy:

See Footnote #2

Daily Record of Vacation and Sick Leave Original:

Term of Employment Plus 3 Years

Daily Record of Budget Expenditures Copy:

See Footnote #2

Daily Record of Budget Expenditures Original:

Completion of audit

Daily Record of Each Employee For Evaluating Copy:

See Footnote #2

Daily Record of Each Employee For Evaluating Original:

2 years

Diet Requisitions From the Floor

Completion of audit

Master Copy of All Types of Diets

Permanent until updated

Menu Files

Destroy in current area

Monthly Patient Meal Census

Completion of audit

Price List of All Foods For Cafeteria Line

Permanent until updated

Purchase of Food Record

Completion of audit

Recommended Daily Nourishment For All Floors

Destroy in current area

Record of All Types Of Diets

Permanent until updated

Record of All Accidents and Incidents

10 years

Record of All Extra Items and Special Luncheons

Completion of audit

Housekeeping

Daily Linen Room Report

1 year

Daily Nursing Station Dismissal Form

Destroy in current area

Environmental Control Project book

5 years

Linen Replacement Record

Completion of audit

Manager's Report

Permanent

Monthly Financial Report

Completion of audit

Project Work Sheet

Destroy in current area

Report of Weekly Inspection

Completion of audit

Supply Orders

Completion of audit

Wheelchair/Card Cleaning Report

1 year

Laboratory

Blood Bank and Cross Match Cards

See Footnote #1

Blood Bank Inventory

Permanent

Daily Charge Ledger Copy:

See Footnote #2

Daily Charge Ledger Original:

Through an Audit

Logs (Specimen logs for each section: tissue, transfusion, etc.)

See Footnote #1

Quality Control Ledger

See Footnote #1

Reports (Histology, Pathology, Chemistry, Hematology, Urinalysis, Bacteriology, Serology, Autopsy)

See Footnote #1

Maintenance

Boiler Temperature Readings

1 year

Conductive Floor and Line Isolation Monitor Test Record

2 years

Elevator Pit Check Sheet

1 year

Equipment and Procedure Test Records

5 years

Fire Drill Log

2 years

Generator Check Sheet

1 year

High Pressure Boiler Log

1 year

Maintenance Equipment Record

1 year

Maintenance Record of Emergency Power Plant

Completion of audit

Record of Daily Work

1 year

Record of Water Analysis

See Footnote #1

Security Incident Report

5 years

Vehicle Service Sheet

Completion of audit

Medical Records

Ambulance Report File

See Footnote #1

Concurrent Review File

See Footnote #1

Death Register

5 Years see RSMo 193.275

Diagnosis Index

See Footnote #1

Immunization Records

When Patient Reaches Age 23 and Has Not Been Seen In 10 Years

In-House Patient File

See Footnote #1

Master Index File

See Footnote #1

Medical and Surgical Audit

See Footnote #1

Newborn Register

5 Years see RSMo 193.275

Operation Index

See Footnote #1

Outpatient Emergency Room File

See Footnote #1

Patient Chart File (Includes All Medical Information Such as Blood Pressure, Weight, Etc.)

See Footnote #1

Physician Index

Permanent until updated

Statistical Reports

Permanent

Nuclear Medicine

Calibration of Survey Meter and Lab Monitor

See Footnote #1

Chi Square Test (Function Test of Spectroscaler)

See Footnote #1

Crystal Resolution of Magnascanner and Spectriscaker

See Footnote #1

Daily Log and Index Cards (Patient Name and Procedure Done)

See Footnote #1

Film Badge Records

Permanent

Function Checks On Dose Calibrator

See Footnote #1

Generator Survey

Permanent

Isotope Dosage Admitted To Patient

See Footnote #1

Isotope Ekuate Assay and Disposition Records

Permanent

Radiation Safety Committee Meetings Records

Permanent

Record of Hot Lab Wipe Test

Permanent

Record of All Pathological Cases

See Footnote #1

Record of Lab and Equipment Check

See Footnote #1

Record of Voltage Calibrations on Machines (Magnascanner and Spectroscaler)

See Footnote #1

Records of Service on All Equipment

See Footnote #1

Records of Wipe Test on Sealed Sources

Permanent

Trash Disposition Records

Permanent

Nursing

Administration of Medication Reports

See Footnote #1

Authorization For Overtime

Completion of audit

Patient Consent To Operate, Anesthesia and other Medical Services

See Footnote #1

Daily Floor Census

1 year

Disciplinary Action Notice Copy:

See Footnote #2

Disciplinary Action Notice Original:

Term of Employment Plus 3 Years

Equipment Transfer Sheets

Completion of audit

Narcotic Count Sheet

Permanent

Narcotic Inventory Control Records

Permanent

Outpatient Sterilization Consent

See Footnote #1

Patient Transfer Form

Permanent

Product Evaluation

1 year

Record of Continuing Education Copy:

See Footnote #2

Record of Continuing Education Original:

Permanent

Request For Admission of Patient To State Cancer Hospital

Permanent

Other Records

Autoclave--Record of Each Load Run

See Footnote #1

Autoclave Test Reports

See Footnote #1

Blueprints of Buildings

Permanent

Building Fund Programs (Including list of pledges made, minutes of committee meetings, contributor lists, donors list, transmittal work sheets along with pledge cards)

Completion of audit

Communicable Disease Reports To State and Local Health Depts. (Rabid animal reports, sexually transmitted disease reports, etc.)

3 years

Consulting Agreements

Term of Agreement & Completion of Audit

Delivery Room Record

Permanent

Departmental Budget Formulation Papers

Completion of audit

Departmental Budgets

Completion of audit

Emergency Room Register Book

See Footnote #1

Emergency Room Reports

See Footnote #1

Emergency Room Sheet (Includes Symptoms, Vital Signs, Business Information and Charges)

See Footnote #1

Hospital Administrative Services Reports

3 years

I.C.U. Admittance Record

See Footnote #1

Property Records (Deeds, titles, leases, etc.)

Permanent

Patient Accounts

Administrative Write Offs

Completion of audit

Bad Debts File

Completion of audit

Charge Tickets

Completion of audit

Employee Discounts

Completion of audit

Guarantor Files

Completion of audit

Guarantor Numbers Issued

Completion of audit

In-House Patient List (Outpatient and Inpatient)

Destroy in current area

Inpatient Commercial and Individual Claims Log

Completion of audit

Insurance Claims (Blue Cross, Medicare, Medicaid, etc.

5 Years--However, if Audit or Litigation is in Process Should Be Kept Through Conclusion of Either

Medicaid Log

Kept Through Conclusion of Federal Regulations

Medicare Log

Kept Through Conclusion of Federal Regulations

Petty Cash Requests

Completion of audit

Purchase of Service Payments

Completion of audit

Record of Bad Debt Admissions

Completion of audit

Transfer Log (Dismissals)

Permanent

Personnel Office

Current Registry and License Verification

Permanent until updated

Personal Information Release

1 year

Terminal Processing Information (Includes Instructions From Employees As To Deductions, Forwarding Addresses, etc.

Term of Employment Plus 3 Years

Transfer Requests

Term of Employment Plus 3 years

Pharmacy

Control Record for Drugs (of what is taken to various units and supply areas, and special requests dispensed to floors)

Permanent

Prescription Record of Orders From Outside Hospital For Inpatients

Permanent

Record of Medicine Charge Copy:

See Footnote #2

Record of Medicine Charge Original:

Through an Audit

Record of Monthly Ledger Copy:

See Footnote #2

Record of Monthly Ledger Original:

Through an Audit

Recording of Class 2, 3, 4, 5 Drugs

Permanent

Recording of Drug Purchases (Non Narcotic)

Permanent

Recording of Drug Orders From Copy of Physician Order

Permanent

Recording of Narcotic Purchases

Permanent

Physical Therapy

Charge Ticket Copy:

See Footnote #2

Charge Ticket Original:

Completion of audit

Consultant Evaluation and Charge Copy:

See Footnote #1

Daily Appointments Record

Permanent

Daily Work Sheets

1 year

Duplicate Daily Charge Slip Copy:

See Footnote #2

Duplicate Daily Charge Slip Original:

Completion of audit

Inpatient Referral and Progress Sheet

See Footnote #1

Monthly Treatment Records and Totals

See Footnote #1

Outpatient Referral and Progress Sheet

See Footnote #1

Physician Requisition

See Footnote #1

Progress Notes On Patients

See Footnote #1

Record Card (Lists Patient and Treatment

See Footnote #1

Record of Equipment Ordered and Received Copy:

See Footnote #2

Record of Equipment Ordered and Received Original:

Completion of audit

Rehabilitation Team Evaluation

See Footnote #1

Rehabilitation Team Staffing

Permanent until updated

Rental Record

Completion of audit

Planning

Capital Expenditure Proposals

Completion of audit

Planning Documents Adopted By the Board of Trustees (Policies, position statements, institutional plans, etc.)

Permanent

Reports Or Commentaries Requested by the Administration For Internal and/or External Distribution

Permanent

Requests For Funding or Technical Assistance(Federal, State or Local)

Federal or State Agency Requirements

Radiology

Daily Log of Patient Exams

See Footnote #1

Envelope and Films On Each Patient

See Footnote #1

Film Badge Report (Report on badges worn by employees to detect exposure to radiation)

Permanent

Final Report of Patient Examination

See Footnote #1

Individual Record of Patient Exams

See Footnote #1

Inspection and Calibration of Equipment

Permanent

Quality Control Records

Permanent

Repairs To Equipment By Outside Repair Companies

Completion of audit

Footnote #1

The Hospital licensing regulations require that hospitals abide by the statute of limitations regarding retention of medical records.

516.105 Actions Against Health Care Providers (Medical Malpractice)--All actions against physicians, hospitals, dentists, registered or licensed nurses, optometrists, podiatrists, pharmacists, chiropractors, professional physical therapists, and any other entity providing health care services and all employees of any of the foregoing acting in the course and scope of their employment, for damages for malpractice, negligence, error or mistake relating to health care shall be brought within two years from date of the occurrence of the act of neglect complained of; a minor shall have the right to assert a claim, thus, retention of medical records for ten (10) years or until a patient's twenty-third (23rd) birthday will ensure that medical records relevant to any such action will be available until the statute of limitations has expired; and except that in cases in which the act of neglect complained of its introducing and negligently permitting any foreign object to remain within the body of a living person, the action shall be brought within two years from the date of discovery of such alleged negligence, or from the date on which the patient in the exercise of ordinary care should have discovered such alleged negligence, whichever date first occurs but in no event shall any action for the damages for malpractice, error, or mistake be commenced after the expiration of ten years from the date of the act of neglect complained of. (Chapter 516 RSMo 1976 Supplement).

The National Association of Medical Records Administrators recommends that medical records be retained for ten years. If feasible, microfilming is a suitable alternative to keeping the hard copy of a document, and requires much less space.

Footnote #2

These items seem to be duplicates of records sent to other departments of the hospital. If they are duplicates they may be destroyed when no longer of reference value, and it has been verified that the original has reached its final destination in the hospital organization.

If these prove to be original documents with no copies then they should be retained for the designated length of time.