Medical Records: Making and Retaining Them: What Is A Medical Record?
Medical Records: Making and Retaining Them: What Is A Medical Record?
Medical Records: Making and Retaining Them: What Is A Medical Record?
Abbreviations
Keep in mind that abbreviations may not be understood by others. Also do not used coded messages to
express exasperation, sarcasm or your poor opinion of the patient.
Altering Medical Records
Please take note that you:
Do not alter notes retrospectively. The courts would view very seriously any attempt to rewrite
notes that will be used as evidence in legal proceedings. If you later discover that something you
have written was inaccurate, misleading or incomplete, insert an additional note as a correction.
Make sure that it is clear to the reader that the new note is a later amendment, and that you are not
attempting to tamper with the original record – date and sign it.
Amend an electronic record by striking through rather than deleting and over-writing the original
entry. After inserting the new, add the date and your name.
Retention Of Records
Statutory limitation periods for an action in negligence to be brought up for hearing after
the alleged negligence occurred vary from country to country. Generally, it is between 3
and 7 years. They do not however, apply to plaintiffs with brain damage; they can bring
a negligence claim at any time because in legal terms they are considered to be minors,
not matter what their chronological age.
As a rule of thumb, most medical records can be safely destroyed when 10 years have
elapsed since the patient was last treated, or since the patient’s death. However, if the
records related to a minor, or are maternity records, they should be kept until the patient
reaches 25 unless he or she is brain-damaged, in which case the records should be kept
until 10 years after his or her death.
In Singapore, the Ministry of Health has defined guidelines for retention of medical records in hospitals.
These were issued in February 1996 and further clarified in the circular of March 1996. The retention
period for primary medical record of all adult hospital surgical patients is 3 years which is the same as that
for adult medical patients. The legal requirement for retention of medical records is 15 years. To comply
with this requirement, the Guideline requires hospitals to retain secondary medical records for these
patients for a further minimum of 17 years. The legal requirements for the retention of medical records are
laid out in the Limitation Act (22/92). Annex 1 shows the retention period for medical records in
Singapore (issued by Ministry of Health, Singapore, in Feb 1996) as well as explanatory notes on what are
primary and secondary records. Such guidelines would be reasonable for medical clinics to follow as well.
References
Joint Commission on Accreditation of Healthcare Organizations. Management of Information. 1996
Accreditation
Manual for Hospitals: Vol 2. JCAHO.
Medical Defence Union. Medical Records. In: Issues in Medical Defence No. 1, 1993:33 -35
Medical Protection Society. Making and keeping medical records. MPS Casebook. Jul 2000:6-8
http://www.mps.org.uk
Ministry of Health, Singapore. Retention Periods for Medical Records – Meeting Legal Requirements.
Circulars No. 1/96 and 3/96.
United Medical Protection. Regulations and Medical Records. United Medical Protection Journal Issue 1,
1999: 14
United Medical Protection. Correcting the Medical Record. Professional Development – downloaded from
United Medical Protection website on 22 November 2000. http://www.unitedmp.com.au
ANNEX 1 - REVISED RETENTION PERIODS FOR MEDICAL RECORDS
(1 FEBRUARY 1996)
Type of Medical Records Retention Period /1 Remarks
Primary Medical Secondary Medical
Records /2 Records /3
(A) HOSPITAL RECORDS
(i) Adult Medical
Inpatient 3 years 17 years ] Exception:
Specialist Outpatient 3 years 17 years ] Where hospital is aware that legal
] action has been initiated, complete
(ii) Adult Surgical ] medical records of patient should
Inpatient 3 years 17 years ] be retained until completion of
Specialist Outpatient 3 years 17 years ] legal proceedings.
]
(iii) Paediatric Medical ] Hospital to stamp “Medico-Legal
Inpatient ] case” prominently on the case
5 years 17 years ] folder of these cases.
Specialist Outpatient 5 years 17 years ]
(iv) Paediatric Surgical ]
Inpatient ]
5 years 17 years ]
Specialist Outpatient 5 years 17 years ]
]
(v) Cancer Records
]
Inpatient till death indefinitely ]
Specialist Outpatient till death indefinitely ]
]
(vi) Psychiatric Records ]
Inpatient 7 years after death of NA ]
patient ]
Specialist Outpatient 7 years after death of NA ]
patient ]
]
(vii) Accident & Emergency ]
Records Hospital A&E Departments to
Accident/Police cases 5 years NA highlight all accident/police cases
Medical cases 3 years NA records by stamping
“Accident/Police Case”
prominently on all the records.
/1 ]
/2 ] Please see explanatory notes attached
/3 ]
- Records to be retained for 3 years at the clinic and a further 2 years at another location
/RE312(RETENTN.DOC) [source: MOH circular 1/96]
NOTES:
1. Retention Period
Retention period refers to the period following the date of last discharge from hospital or last
attendance at the Outpatient Clinic.
2.1 Primary Medical Records refer to all the original inpatient and outpatient records generated at the
time of admission or outpatient attendance.
2.2 After the specified period of retention, primary records must be culled by extracting the forms
listed in para 3 below, which will be assembled to form the Secondary Medical Records
4. Microfilmed Records