Medical Center Records (UIC) Retention Schedule

Notice:

The information contained on this schedule is the minimum State-required retention period for the specified categories. This does NOT authorize disposal action. State approval is expressly required prior to each disposal of records, regardless of format or volume, unless the documents are specifically categorized as non-records. Contact the RIMS office to initiate a records disposal or for the State approved retention period of any items not listed below.

RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so. However, if your records are subject to a legal hold or pending legal action, you will need to follow the retention recommended by legal counsel. RIMS should be notified of any decisions to keep records past their minimum retention.

Upon completion of the retention period for medical center records they will either be deleted, destroyed, or transferred to the University Archives. Before the retention period expires, please follow the records storage guidelines. For questions or more clarification about the correct process for these actions, please contact the RIMS office.

The Notes column includes pertinent information about the documents, if known, such as the Office of Record and System of Record. If you have a document that does not appear below or if you have further information about the Office of Record or System of Record, please contact RIMS.

A PDF version of this retention schedule is available. Download

The categories of Medical Center Records are:

Patient Medical Records

Patient Medical Records include documents relevant to each service a patient receives, containing sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course of treatment and results, and promote continuity of care among health care providers. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Intake forms	25 years past the date of service, then obtain State approval to dispose
Lab results	25 years past the date of service, then obtain State approval to dispose
Listings of medications prescribed	25 years past the date of service, then obtain State approval to dispose
Doctors' notes	25 years past the date of service, then obtain State approval to dispose
Diagnoses	25 years past the date of service, then obtain State approval to dispose
Reports of services received	25 years past the date of service, then obtain State approval to dispose
Treatments	25 years past the date of service, then obtain State approval to dispose
Tests	25 years past the date of service, then obtain State approval to dispose
Record of patient instruction	25 years past the date of service, then obtain State approval to dispose

Birth Certificate Worksheets

The birth certificate worksheet consists of information used to create birth certificates such as legal name of the child to appear on the birth certificate and information on the mother and father. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Birth Certificate Worksheet	Permanently, see RIMS for guidance

Immunization and Vaccine Records

The Immunization and Vaccine Records are a record of each patient's history of receiving immunizations and vaccines at the University of Illinois Medical Center. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Immunization records	Permanently, see RIMS for guidance

Patient Master Index File

The Patient Master Index File consists of a chronological log per patient of each service provided. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Patient Master Index File	Permanently, see RIMS for guidance

Fetal Monitoring Records

Fetal Monitoring Records consist of the record of activity of a fetus immediately prior to birth. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Fetal monitoring strips	25 years from the date of birth then obtain State approval to destroy

Blood Bank Donor/Recipient Records

Blood Bank Donor/Recipient Records include documents that record names of persons or entities who donate blood, receive blood, or are unable to donate blood for various reasons. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Lists of persons or entities donating blood	10 years from the date of service, then obtain State approval to dispose
Lists of persons or entities receiving blood	10 years from the date of service, then obtain State approval to dispose
Lists of persons permanently deferred from donating	75 years from date of attempted donation, then obtain State approval to dispose

Blood Bank Training and Qualification Records

Blood Bank Training and Qualification Records consist of documentation indicating that employees have successfully completed the necessary training. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Blood Bank Employee Training records	5 years past the date of training then obtain State approval to destroy
Blood Bank Employee Qualification records	5 years past the date of training then obtain State approval to destroy
Blood Borne Pathogens Training (OSHA) records	5 years past the date of training then obtain State approval to destroy

Blood Bank Control Records

Blood Bank Control Records consist of documentation indicating blood bank compliance with common safety and protocol policies for managing a blood bank. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Equipment performance checks/audits	10 years past the date of equipment function then obtain State approval to destroy
Equipment preventative maintenance records	10 years past the date of preventative maintenance then obtain State approval to destroy
Centrifuge calibration records	10 years past the date of calibration then obtain State approval to destroy

Imaging Services Records

Imaging Services Records include results from radiology and cardiology procedures and tests. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Mammography records	10 years past the date of service or procedure then obtain State approval to destroy
Mammograms	10 years past the date of service or procedure then obtain State approval to destroy
Mammography images/films	10 years past the date of service or procedure then obtain State approval to destroy
Mammography reports	10 years past the date of service or procedure then obtain State approval to destroy
Test results	5 years past the date of service then obtain State approval to destroy
Electrocardiogram (EKG or ECG) tracings	5 years past the date of service then obtain State approval to destroy
Electroencephalogram (EEG) tracings	5 years past the date of service then obtain State approval to destroy
Electromyogram (EMG) tracings	5 years past the date of service then obtain State approval to destroy
Films	5 years past the date of service then obtain State approval to destroy
Slides	5 years past the date of service then obtain State approval to destroy
Scans	5 years past the date of service then obtain State approval to destroy
Tapes	5 years past the date of service then obtain State approval to destroy
Pictures	5 years past the date of service then obtain State approval to destroy
Videotapes	5 years past the date of service then obtain State approval to destroy
X-ray photographs/films	5 years past the date of service then obtain State approval to destroy
Roentgen photographs	5 years past the date of service then obtain State approval to destroy
Radiopharmaceutical tests	5 years past the date of service then obtain State approval to destroy

Laboratory Records

Laboratory Records consist of laboratory procedures and documentation related to tests conducted on patient specimens. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Laboratory quality assurance documents/reports	10 years past the date of service then obtain State approval to dispose
Laboratory quality control documents/reports	10 years past the date of service then obtain State approval to dispose
Laboratory procedures	10 years past the date of service then obtain State approval to dispose
Laboratory reports	10 years past the date of service then obtain State approval to dispose
Histopathology slides	10 years past the date of service then obtain State approval to dispose
Histopathology specimen blocks	10 years past the date of service then obtain State approval to dispose
Cytology slides	10 years past the date of service then obtain State approval to dispose
Pathology logs	10 years past the date of service then obtain State approval to dispose
Pathology reports	10 years past the date of service then obtain State approval to dispose
Record of blood draws/drawers	10 years past the date of service then obtain State approval to dispose
Immunohematology records	5 years past the date of service then obtain State approval to dispose
Specimen records	5 years past the date of service then obtain State approval to dispose
Lab test requisitions	5 years past the date of service then obtain State approval to dispose
Non-clinical lab studies records	5 years past the date of service then obtain State approval to dispose

Pharmacy Records

Pharmacy Records consist of documents relating to dispensing, administering, acquiring, and verifying prescriptions of controlled medicinal substances. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Receipts for narcotics dispensing	3 years past the date of dispensing then obtain State approval to dispose
Acquisitions order forms	3 years past the date of dispensing then obtain State approval to dispose
Records of narcotic drugs administered	3 years past the date of dispensing then obtain State approval to dispose
Records of prescriptions dispensed	5 years past the date of dispensing then obtain State approval to dispose
Verification log of Schedule III and IV Controlled Substance prescription refills	5 years past the date of prescription refill verification then obtain State approval to dispose
Facsimile copy of a prescription	5 years past the date of dispensing then obtain State approval to dispose
Written memorandum of the oral prescription	5 years past the date of dispensing then obtain State approval to dispose
Prescription refills	5 years past the date of prescription refill verification then obtain State approval to dispose

Patient Encounter Forms

Patient Encounter Forms include forms completed by the physician to document services and procedures rendered to the patient. RIMS recommends that no record be held for more than one (1) year beyond its listed mandatory minimum retention period and that they only be retained for longer if there is a legitimate business need to do so.

Documents	Retention	Notes
Patient Encounter Form	Provided all pertinent information has been transferred to other records (i.e., central billing databases and/or medical records), 3 years from date of service then obtain State approval to dispose
Emergency Room transfer	Provided all pertinent information has been transferred to other records (i.e., central billing databases and/or medical records), 3 years from date of service then obtain State approval to dispose
Sexual Assault Survivor Emergency Treatment	Provided all pertinent information has been transferred to other records (i.e., central billing databases and/or medical records), 3 years from date of service then obtain State approval to dispose

Primary Audience

This schedule will specifically help those who work with patient records, such as staff from the University of Illinois Hospital and Health Sciences System, University Health Services at UIC, and Health Service at UIS.

Contributors

Our many thanks to the following contributors who worked with us to create this schedule through discussion, collaboration, input, and consensus:

UI Hospital, Health Information Management – Margaret Pajak
UI Hospital, Quality Management Department – Natalie Chadwell, Maureen Perry, Stephanie Wright
UI Hospital, Information Services – Karen Engelhardt
UI Hospital, Pharmacy – John Garofalo
UI Hospital, Administration – Samuel Levin, David Loffing
UI Hospital, Nursing Services – Carolyn McLane
UI Hospital, Ambulatory Services Administration – Nicole Rush
UIC Office for Access and Equity – Steve Holz
University Counsel – Laura Clower
UIUC University Archivist – William Maher