Society

Instructions:  Write 3 essays from the questions offered below and answer each of your selections in CONCISE essay form 3 pages or less for each question. Your essays can also include maps, tables, lists, pictures, or other graphic materials, if you feel these will help support your argument and explanation, and these materials will not count towards the total pages. It is important to remember that there is no right answer to any of these questions. The best answer will be one that reflects your thoughtful consideration of the information we have covered this semester, supported by points raised in our discussions and in our readings and other literature that you may discover through new research. Please submit your written responses in an email message to me in one composite Word file.

Assess and Identify and describe some of the specific threats you see that have altered the biodiversity in the area of your home as a result of human economies and livelihoods (choose the place you feel best represents home for you) refer to the categories we reviewed in our class on Threats to Biodiversity. Then list some specific solutions you feel could be used to try to reduce, mitigate, or reverse these threats.
 
Describe 3 policies you think could realistically be established by state or federal government to help reduce the threats to wildlife and biodiversity from the adverse impacts we are having on the climate. Make certain that your suggestions are ones that could realistically be accepted by the public. What arguments would you use to convince politicians to adopt these policies, and the public to abide by them?

You have taken a job with Citibank as part of their Sustainable Finance division. Citibank provides loans to companies and governments in 140 countries, and many of their loans are for projects that involve agriculture and forest development; energy (including both renewable and non-renewable sources); road construction; manufacturing; tourism; and other sectors that can have a significant impact on ecosystem services, habitats, and biodiversity. You have been asked to develop the criteria to be used to make certain that any projects financed by Citibank through their loans do not threaten biodiversity or ecosystem services. Your criteria will be used by bank employees as part of their Environment-Social-Governance (ESG) standards in order to screen requests for loans to finance projects greater than $5,000,000 in value. List the criteria you will recommend they include to safeguard biodiversity and ecosystem services. Explain how each criterion provides a mechanism to provide good accountability for risks to nature and biodiversity.

Your outside reading for this week discusses the similarities and differences between the LHR (legal health record) and the DRS (designated record set).  

1.   Designation

 

Your outside reading for this week discusses the similarities and differences between the LHR (legal health record) and the DRS (designated record set).    For this assignment, you will access an excel file that contains some of the documents or files that are to be reviewed.  See above link for template.  This is not an exhaustive list.  For each element, you will indicate the primary source of the document.  For example, if your institution has an electronic capture of consent forms, then the source would be the EHR documentation system.  But if consent forms are still done via a paper form, then you would indicate that the source is paper.   Examples of the primary sources are given below.  This is not a complete list, so if your institution has a different source for the information, you are free to use that.

 

Examples of Primary Sources

 

Paper

CPOE

Nursing documentation system

EHR documentation system

PACS (Picture Archiving and Communication System)

Transcription

Financial System

Administration system

Admitting documentation system

 

 

 

You will also indicate if the document/file is part of the Designated Record Set or the Legal Health Record. Part of the assignment includes formatting the file in a way that is user friendly to the reader.  This may include regrouping some of the items, using shading or borders to help the end user find information, or you may need to add additional columns to capture the information you feel is important (although additional columns are not required).  If your entries do not fit into the template column width, please format so that the entry is wrapped in the cell.

 

The comment section can be utilized for any clarification you may wish to make.

 

 

 

2.   Retention

 

In addition, you will research the retention requirements for these documents.  In some areas, there are no specific guidelines.  It is up to the institution to determine the retention period.  If you cannot find a specific time period, either check with your institution, or use your best judgement and indicate your reasoning in the comment section.

 

 

 

Resources

 

State Medical Record Laws.  Table A-7. HealthIT.   https://www.healthit.gov/sites/default/files/appa7-1.pdf

 

Retention and Destruction of Health Information.  AHIMA.  2013.  (http://library.ahima.org/PB/RetentionDestruction#.V9LcAzW8JsU

 

 

 

The post Your outside reading for this week discusses the similarities and differences between the LHR (legal health record) and the DRS (designated record set).   appeared first on homework handlers.

Data Mapping and Its Impact on Data Integrity

Data Mapping and Its Impact on Data Integrity

 

 

DATA MAPPING AND ITS IMPACT ON DATA INTEGRITY

AUTHORS AND CONTRIBUTORS: Linda Hyde, RHIA; Theresa Rihanek, MHA, RHIA, CCS; Terry Santana-Johnson, RHIT, CDIP, CCS, CCS-P; Rita Scichilone, MHSA, RHIA, CCS, CCS-P; Cortnie Simmons, MHA, RHIA, CCS; Jane Beth Turner, RHIA; Wendy Zumar, MA, RHIA, CCS

ACKNOWLEDGEMENTS: Sue Bowman, MJ, RHIA, CCS, FAHIMA; June Bronnert, RHIA, CCS, CCS-P; Marlisa Coloso, RHIA, CCS; Angie Comfort, RHIT, CDIP, CCS; Katherine Downing, MA, RHIA, CHP, PMP; Lesley Kadlec, MA, RHIA; Cheryll Rogers, RHIA, CDIP, CCS, CTR; Joanne Romasko, RHIA, CPC, CHDA; Rayna Scott, RHIA, CHDA, MS

EDITOR: Anne Zender

DESIGN: Maria Sitelis

Representing more than 71,000 specially educated health information management professionals in the United States and around the world, the American Health Information Management Association is committed to promoting and advocating for high quality research, best practices, and effective standards in health information and to actively contributing to the development and advancement of health information professionals worldwide. AHIMA’s enduring goal is quality healthcare through quality information.

© 2013

ahima.org

 

 

DATA MAPPING AND ITS IMPACT ON DATA INTEGRITY

1 | AHIMA

INTRODUCTION

The current rise in data mapping projects is the result of the need to link disparate electronic data systems in a rapidly changing environment. Mapping projects are valuable in a variety of situations where data elements from one code or data set are compared to another set and evaluated for equivalence of meaning to accomplish a defined “use case.” Code sets related to health information functions include CPT and its modifiers, ICD-9-CM, ICD-10-CM/PCS, and HCPCS level II, as well as LOINC, Rx NORM, and SNOMED CT®. Additionally, quality measures such as those used by the Agen- cy for Healthcare Research and Quality and National Quality Forum are frequently linked to these code sets and may require internal mapping to ensure accurate measurement. Data mapping is not limited to just these code sets; there are many different types of maps in the healthcare realm.

The increased demands for data sharing and interoperability, especially across different practice settings and different classification systems, increase reliance on data mapping tools and techniques. The use of these tools requires frequent integrity checks. Understanding the role and context of data maps, as well as their strengths and weaknesses, is essential in ensuring the reliability of the data entries derived from maps. Data mapping tasks may be as simple as matching a provider’s administrative codes for disposition to an external standard such as UB-04 or taking a more complex clinical condition and creating a standard representation across different standardized representations. In all situations employing maps, processes and guidelines must be clearly defined and documentation prepared to explain how the map was created, tested, and performing correctly for its intended use case.

Thinking through the risks and unintended consequences of map use is mandatory before any projects are planned. Careful consideration of liability is required before any mapping between disparate sources is attempted for healthcare situations.

This thought leadership paper explores the relationship of data mapping and data integrity assurance by providing guidance to avoid adverse outcomes involving the use of maps.

Information management projects are data-centric projects. Data mapping requires knowledge of information technology, the data sets being mapped, and project management, which often requires a diverse team approach. Health information management (HIM) professionals are frequently involved in planning and developing data maps that utilize code sets, as there is a need for competency in both the source and target systems involved in the mapping projects. The source is the origin of the map or the data set from which one is mapping. The target is the data set in which one is attempting to find equivalence or define the relationship.1 Figure 1 depicts the typical mapping process.

All installed and active software maps of any kind must be identified, inventoried, and checked for validity. Poorly designed and out-of-date mappings create significant data integrity problems in health information systems. Undetected errors in data maps have the potential to introduce many problems, including the filing of false claims to insurers, delivering the wrong information for patient care and/or quality measures, or causing a breach in patient privacy.

Figure 1 Mapping Workflow

• Project Plan

• Use Case Development

• Testing

• Maintenance • Data Integrity

Risk

• Validation Required

Source

Mapping

Target

 

 

DATA MAPPING AND ITS IMPACT ON DATA INTEGRITY

2 | AHIMA

EXAMPLES OF DATA INTEGRITY INVOLVING MAPPING Ensuring data integrity when data maps are present requires diligence to ensure:

• Trustworthiness of mapped information over its life cycle and use

• Integrity is accomplished by validation and regular “checkups” of the data flow and map performance.

• Mapped entries reflect current content through the entire workflow, consistent with the use case for the map in both primary and secondary uses of the same data.

– Integrity is achieved by monitoring the mapping results specific to the use case and how those results are repurposed for other uses.

• Maintain the intended content of a validated map, in case the mapped data structure changes through data processing. Ongoing vigilance is required to test results of the map.

• The map provides uniform, reliable, complete, and unchanged semantic output through data stewardship protocols.

DANGERS OF INAPPROPRIATE MAPPING When evaluating data integrity issues involving mapping, it’s critical to understand the elements of all the code sets or data sets being mapped. The strengths and weaknesses of each source or code set, their intended use, and how the map is created are all important to building a successful data map. Using a map for a purpose not intended or misunderstanding the construct of the source and target can lead to incomplete, incorrect, and inappropriate maps. The following examples illustrate several key issues related to inappropriate mapping practices:

• SNOMED CT is a comprehensive clinical terminology that contains content for both human and veterinary medicine. SNOMED CT hierarchies are complex and require careful consideration in developing heuristics and guidelines. The structure supports terms within the hierarchy commonly referred to as a “parent” or “child.” The definition of a subtype is a (SNOMED CT) concept that has a direct subtype relationship to a specified concept.2 SNOMED CT also includes (subtype) descen- dants that are all subtypes of a concept, including subtypes of subtypes. For example, if a concept has four children, then descendants are those children plus all the concepts descended from those four children.

• When exporting concepts for a map using SNOMED CT, it is critical to ensure the correct reference set is used to exclude terms exclusively used for non-human concepts when working on human-only content.

• For example, when there are child terms for a selected parent concept, all children should be reviewed for inclusion in the map. Children of the term “aneurysm” include both acquired and congenital aneurysms, but the map may only be intended to identify acquired conditions.

• When deploying maps for health record use, the integrity of results will be compromised if the source system entry does not represent valid health record content precisely (that is, semantic match). Data maps cannot provide context or inference of content or integrity. It’s important to build in steps to ensure appropriate structure and validation of the map before it is used, and to test in the “live” environment to ensure there are no errors in the data processing cycle.

 

 

DATA MAPPING AND ITS IMPACT ON DATA INTEGRITY

3 | AHIMA

• When developing maps for health records or clinical data management, take care to ensure reliability of the results. Maps should not be used as a substitute for health record encoding. Maps are created without context and information available to assign codes for health records as a source for admin- istrative purposes including reimbursement for care. For example, the term “allergy to penicillin” can be appropriately coded when the context of the health record reveals this is a history or status rather than an acute allergic reaction. However, in mapping, this same contextual information is not available, which requires guidance for the user to confirm results.

• Creating maps internally and using unqualified personnel in map development compromises integrity of results. Use skilled personnel familiar with data mapping requirements, limitations, and pitfalls to ensure reliable results.

• Using maps for healthcare claims can lead to compliance issues or even allegations of fraud if the map results in incorrect code submission linked to health insurance billing for reimbursement.

Exploring the Importance of Business Rules and Map Heuristics

Data mapping is a key component of requirements analysis. This analysis needs to be completed by a subject matter expert early in the project or after the mapping has been completed but not yet deployed. It’s essential to carefully plan and assess requirements, since mapping projects require time, skills, and effort that may be costly. Data maps should not be attempted if there is a more direct process available for the use case. In data mapping, planning time spent to ensure integrity of the map performance can be provided on the front-end or back-end project planning.

All maps require an investment of time and resources, and some mapping projects may require more than others. When the source data and the target data are similar in structure with a high percentage of exact matches in content and meaning, the time needed for validation will be minimal. However, when the source and target do not result in an exact match, time must be spent to determine which of the choices are appropriate based on the map’s use case. Unless the mapping is a one-to-one match from source to target, decisions must be made to meet the intent of the map.

The adoption of business rules adds another tier to systems that automate business processes. For mapping projects, this is often referred to as map heuristics. If there is a one-to-one match from source to target information, automated systems are able to perform the mapping activity with little human intervention. If this is not the case, a commitment of time must be applied to the mapping process to ensure the end result meets the map’s intent and conforms to the project’s use case. Subject matter experts managing or reviewing the map must be well versed concerning source data with guidance on what the target data should be.

For example, specific expertise in the use of Current Procedural Terminology may be required to understand how to map codes correctly for their intended use in professional fee billing. For this reason, optimal mapping results require a comprehensive understanding of how the mapped data will be used. A functional requirement, guideline, or use case is required to ensure maps will be consistent across the application of all data requirements. Mapping heuristics are “rule of thumb” guidance that provide rules for how to map from source to target in a consistent manner. Detailed instructions are provided so consistency is ensured between map developers throughout the project. Every mapping project must have clear instructions to make the map results “understandable, reproducible, and reliable.” 3, 4

Along with a well-documented use case describing the need for a map and its intended purpose, heuristics are essential for mapping success. It is imperative that decisions made regarding business rules and map heuristics are clearly documented so evidence is available describing why each decision was made and by whom. This serves as an audit trail of decisions made during the mapping process.

 

 

DATA MAPPING AND ITS IMPACT ON DATA INTEGRITY

4 | AHIMA

Mapping is almost always a resource-intensive project requiring hands-on review and considerable knowledge about the source and target. Human intervention is necessary for mapping design and validation of map outcomes. Mapping tools may assist in the process by providing varying degrees of automation. Manual review is required, to a varying extent, to map the portions that failed auto- mated mapping and to validate the results of automated mapping. The defined map development rules must be reproducible in order to validate mapping(s), regardless of whether it was accom- plished by automated or manual means. Assumptions may be used with caution in data mapping when they are fully defined and included in the documentation of the use case and can be relied on to produce results without data integrity errors. For example, the ICD-10-CM/PCS to ICD-9-CM reimbursement mappings assume the use case is for inpatient admissions and reimbursement.5

REVIEWING VENDOR MAPS For all managers of health information, it is important to identify all existing applications that are using maps of any kind for health information use, including those involving clinical terminology systems as a source or target. The vendor should be able to provide a list of maps that transpose or translate one data set to another being used for review. HIM professionals should be aware of and monitor these, since there is significant potential for error if the vendor is not keenly aware of the content and how it is designed to be used. This documentation should include a data dictionary to provide a complete definition and the intended use of each data component. The data dictionary will ensure the interpreted meaning of the data element is correct. For example, a field for “Provider ID” could have many different definitions such as billing identification number, national provider identifier, social security number, and so forth.

End users should create an acceptance testing process to verify the map as part of their decision to purchase the product. Such maps may be as simple as admit, discharge, and transfer information mapped into products, or as complex as provider maps that determine under which provider a bill may be submitted. Validity testing protects against mapping errors that threaten the integrity of the mapped results.

Linking data from one coded data system to another is rarely perfect and even subtle differences in the meaning can cause integrity problems. When the source and target are not a semantic match, the problems begin when a word or term has more than one meeting and the context is not available to the user and assumptions are made.

MAINTENANCE PROCESS OF MAPS CANNOT BE IGNORED The source and target systems for any map are expected to change over time. In some cases, these systems have periodic, regularly scheduled updates such as ICD-9-CM or ICD-10-CM, or release dates for SNOMED CT. If a map is created between ICD-10-CM and SNOMED CT, which both have different update schedules, this makes the maintenance schedule more complex and costly, but the mainte- nance is necessary to keep the map functioning properly. This maintenance process not only needs to accommodate the addition of new codes, but also the retirement of existing codes, changes in the code description, or any other change. When revisions or deletions are made in the code sets and these codes are used in a map, versioning is needed so that historical data that uses this map is not adversely affected. Versioning provides a reference to ensure that maps that were current in a given time period are still valid going forward, but replaced with current maps for the current time period.

 

 

DATA MAPPING AND ITS IMPACT ON DATA INTEGRITY

5 | AHIMA

MAPPING PROCESS AND TOOLS AFFECTING DATA INTEGRITY The challenges are numerous in electronic systems and workflows. These include:

• Drop-down pick lists for recording clinical facts generated from maps, which may result in inappropriate or less specific selections

• Computer-assisted encoding software automation submitting codes that misrepresent the facts of the encounter

• Use of templates developed from mapped data, which may exaggerate the clinical facts or omit important input

• Workflows involving maps resulting in the submission of non-specific or inappropriate codes or data elements

• Forgetting to update maps when the source and target systems have mapped items changed or discontinued

• Automated mapping producing errors without detection

• Interface engines that employ maps that are not functioning properly

• Default responses used within rule-based maps resulting in inaccurate results

• Duplicate data entries if software applications are employing maps and manual data entry is submitted through a separate process

• System override capabilities cancel the use of the map for health records and the ability to copy information from one source and paste it into another affects the integrity of the map’s target

Awareness of these common areas of concern should bring additional scrutiny to the data mapping planning process. For example, a billing system designed to facilitate claims submission may have certain items mapped incorrectly for deployment through an interface, causing the host system to house the correct data, with the “mapped to” results returning an incorrect value. Another possible issue may arise when a source field is mapped to the wrong field (as opposed to the wrong value) in the destination system. For all these reasons, careful design of the map and validity of the setup is required.

Data integrity includes the ability to depend on finding the accurate data and being able to trust its reliability. Having the data stored once increases reliability and reduces the opportunity for conflicting results. Data dictionaries assist in ensuring that data is requested once and that results are consistent.

VALIDITY TESTING FOR DATA INTEGRITY ASSURANCE While testing is an important component of development of any application or system, it must continue after the application is released for use. Validity testing for data maps needs to occur on a regular basis in the production environment to verify the map is still being used for its intended purpose and is consistently delivering accurate mapping results. This can be accomplished using a random sampling basis or by focusing on the maps in search of high-volume data to watch for data integrity problems. A monthly validation report on a field-by-field basis which includes the benchmark is helpful to quickly identify any potential new mapping issues that have developed. For example, if the field “Referring Physician” is typically populated 83 percent of the time and this month’s validation report shows there is a decrease to 70 percent, this is a red flag requiring research to identify the source prior to using the data. Whenever possible, validity testing should be conducted in the “live” environment to ensure end-to-end integrity of the content.

 

 

DATA MAPPING AND ITS IMPACT ON DATA INTEGRITY

6 | AHIMA

RECOMMENDATIONS FOR BEST PRACTICES TO AVOID DATA MAPPING ERRORS Any data integrity process is an integral part of a data stewardship program. Data stewardship involves administering the organization’s data assets to ensure ongoing usability, accessibility and quality. Recommendations to avoid data mapping errors include:

• Document the map heuristics and standing business rules surrounding the development of each map.

– These rules would include well developed use cases for each map, the identification of applications that would utilize the map, and documentation to explain how mapping rules are created and deployed in the workflow.

• Create a program and process to test the validity and reproducibility of the map. – A testing program should cover the development process of the map and any associated

tools used from map development to end-user acceptance testing and approval.

• Create and implement a maintenance program. – Source and target code sets for any map may be subject to change due to periodic

updates, removal from source or target data sets, discontinuation, or major version changes from either end of the map.

Notes

1. AHIMA. “Data Mapping Best Practices.” Journal of AHIMA 82, no. 4 (April 2011): 46—52. Available in the AHIMA Body of Knowledge at ahima.org.

2. International Health Terminology Standards Development Organisation. “SNOMED CT User Guide.” July 2013. http://ihtsdo.org/fileadmin/user_upload/doc/download/doc_UserGuide_ Current-en-US_INT_20130731.pdf.

3. Foley, Margaret, et al. “Translation Please: Mapping Translates Clinical Data between the Many Languages That Document It.” Journal of AHIMA 78, no. 2 (February 2007): 34—38. Available in the AHIMA Body of Knowledge at ahima.org.

4. AHIMA. “Data Mapping Best Practices.”

5. Centers for Medicare and Medicaid Services. “ICD-10-CM/PCS to ICD-9-CM Reimbursement Mappings.” 2013. http://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-CM-and-GEMs.html.

References

AHIMA. “Putting the ICD-10-CM/PCS GEMs into Practice.” Updated May 2013. Available in the AHIMA Body of Knowledge at ahima.org.

International Health Terminology Standards Development Organisation. “IHTSDO Glossary.” January 2013. http://www.ihtsdo.org/fileadmin/user_upload/doc/en_us/gl.html

Wilson, Patricia, “What Mapping and Modeling Means to the HIM Professional.” Perspectives in Health Information Management 4;2, Spring 2007. Available at http://perspectives.ahima.org/what- mapping-and-modeling-means-to-the-him-professional/#.Uk7qsxD3Jn0.

Solberg, Jeanne, Susan White, Jill Clark, and Linda Hyde. “Data Stewardship and HIM, Keep the Meaningful in Data Use.” Workshop presented at the AHIMA Annual Conference, Salt Lake City, UT, October 2011.

 

http://www.ahima.org
http://ihtsdo.org/fileadmin/user_upload/doc/download/doc_UserGuide_Current-en-US_INT_20130731.pdf
http://ihtsdo.org/fileadmin/user_upload/doc/download/doc_UserGuide_Current-en-US_INT_20130731.pdf
http://www.ahima.org
http://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-CM-and-GEMs.html
http://www.ahima.org
http://www.ihtsdo.org/fileadmin/user_upload/doc/en_us/gl.html
http://perspectives.ahima.org/what-mapping-and-modeling-means-to-the-him-professional/#.Uk7qsxD3Jn0
http://perspectives.ahima.org/what-mapping-and-modeling-means-to-the-him-professional/#.Uk7qsxD3Jn0

The post Data Mapping and Its Impact on Data Integrity appeared first on homework handlers.

Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals*

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals*

Summary of statutory or regulatory provision by entity.

State Medical Doctors Hospitals

Alabama As long as may be necessary to treat the patient and for medical legal purposes. Ala. Admin. Code r. 545-X-4-.08 (2007).(1)

5 years. Ala. Admin. Code § 420-5-7.10 (adopting 42 C.F.R. § 482.24).

Alaska N/A Adult patients 7 years following the discharge of the patient. Minor patients (under 19) 7 years following discharge or until patient reaches the age of 21, whichever is longer. Alaska Stat. § 18.20.085(a) (2008).

Arizona Adult patients 6 years after the last date of services from the provider. Minor patients 6 years after the last date of services from the provider, or until patient reaches the age of 21 whichever is longer. Ariz. Rev. Stat. § 12-2297 (2008).

Adult patients 6 years after the last date of services from the provider. Minor patients 6 years after the last date of services from the provider, or until patient reaches the age of 21 whichever is longer. Ariz. Rev. Stat. § 12-2297 (2008).

Arkansas N/A Adult patients 10 years after the last discharge, but master patient index data must be kept permanently. Minor patients Complete medical records must be retained 2 years after the age of majority (i.e., until patient turns 20). 016 24 Code Ark. Rules and Regs. 007 § 14(19) (2008).

California N/A(1) Adult patients 7 years following discharge of the patient. Minor patients 7 years following discharge or 1 year after the patient reaches the age of 18 (i.e., until patient turns 19) whichever is longer. Cal. Code Regs. tit. 22, § 70751(c) (2008).

Colorado N/A(1) Adult patients 10 years after the most recent patient care usage. Minor patients 10 years after the patient reaches the age of majority (i.e., until patient turns 28). 6 Colo. Code Regs. § 1011-1, chap. IV, 8.102 (2008).

(continued)

A-68

 

 

 

 

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals* (continued)

State Medical Doctors Hospitals

Connecticut 7 years from the last date of treatment, or, upon the death of the patient, for 3 years. Conn. Agencies Regs. § 19a-14-42 (2008).

10 years after the patient has been discharged. Conn. Agencies Regs. §§ 19-13-D3(d)(6) (2008).

Delaware 7 years from the last entry date on the patient’s record. Del. Code Ann. tit. 24, §§ 1761 and 1702 (2008).

N/A

District of Columbia

Adult patients 10 years following the date of discharge of the patient. 3 years after last seeing the

patient. Minor patients 3 years after last seeing the patient or 3 years after patient reaches the age of 18 (i.e., until patient turns 21). D.C. Mun. Regs. tit. 17, § 4612.1 (2008).

D.C. Mun. Regs. tit. 22, § 2216 (2008).

Florida 5 years from the last patient contact. Fla. Admin. Code Ann. 64B8- 10.002(3) (2008).

Public hospitals: 7 years after the last entry. Florida Department of State, General Records Schedule GS4 for Public Hospitals, Health Care Facilities and Medical Providers, (2007), http://dlis.dos.state.fl.us/barm/genschedul es/GS04.pdf (accessed September 12, 2008).

Georgia 10 years from the date the record item was created. See Ga. Code Ann. § 31-33- 2(a)(1)(A) and (B)(i) (2008).

Adult patients 5 years after the date of discharge. Minor patients 5 years past the age of majority (i.e., until patient turns 23). See Ga. Code Ann. §§ 31-33-2(a)(1)(B)(ii) (2008); 31-7-2 (2008) (granting the department regulatory authority over hospitals) and Ga. Comp. R. & Regs. 290- 9-7-.18 (2008).

Guam N/A N/A (continued)

A-69

 

http://dlis.dos.state.fl.us/barm/genschedules/GS04.pdf
http://dlis.dos.state.fl.us/barm/genschedules/GS04.pdf

 

 

 

 

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals* (continued)

State Medical Doctors Hospitals

Hawaii Adult patients Full medical records: 7 years after last data entry. Basic information (i.e., patient’s name, birth date, diagnoses, drugs prescribed, x-ray interpretations): 25 years after the last record entry. Minor patients Full medical records: 7 years after the patient reaches the age of majority (i.e., until patient turns 25). Basic information: 25 years after the minor reaches the age of majority (i.e., until patient turns 43). Haw. Rev. Stat. § 622-58 (2008).

Adult patients Full medical records: 7 years after last data entry. Basic information (i.e., patient’s name, birth date, diagnoses, drugs prescribed, x- ray interpretations): 25 years after the last record entry. Minor patients Full medical records: 7 years after the minor reaches the age of majority (i.e., until patient turns 25). Basic information: 25 years after the minor reaches the age of majority (i.e., until patient turns 43). Haw. Rev. Stat. § 622-58 (2008).

Idaho N/A Clinical laboratory test records and reports: 5 years after the date of the test. Idaho Code Ann. § 39-1394 (2008).

Illinois N/A 10 years. See 210 Ill. Comp. Stat. 85/6.17(c) (2008).

Indiana 7 years. Burns Ind. Code Ann. § 16-39-7-1 (2008).

7 years. Burns Ind. Code Ann. § 16-39-7-1 (2008).

Iowa Adult patients 7 years from the last date of service. Minor patients 1 year after the minor attains the age of majority (i.e., until patient turns 19). See Iowa Admin. Code r. 653- 13.7(8) (2008); Iowa Code § 614.8 (2008).

N/A

Kansas 10 years from when professional service was provided. Kan. Admin. Regs. § 100-24-2 (a) (2008).

Adult patients Full records: 10 years after the last discharge of the patient. Minor patients Full records: 10 years or 1 year beyond the date that the patient reaches the age of majority (i.e., until patient turns 19) whichever is longer. Summary of destroyed records for both adults and minors—25 years. Kan. Admin. Regs. § 28-34-9a (d)(1) (2008).

(continued)

A-70

 

 

 

 

 

 

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals* (continued)

State Medical Doctors Hospitals

Kentucky N/A Adult patients 5 years from date of discharge. Minor patients 5 years from date of discharge or 3 years after the patient reaches the age of majority (i.e., until patient turns 21) whichever is longer. 902 Ky. Admin. Regs. 20:016 (2007).

Louisiana 6 years from the date a patient is last treated. La. Rev. Stat. Ann. § 40:1299.96(A)(3)(a) (2008).

10 years from the date a patient is discharged. La. Rev. Stat. Ann. § 40:2144(F)(1) (2008).

Maine N/A Adult patients 7 years. Minor patients 6 years past the age of majority (i.e., until patient turns 24). See 10-144 Me. Code R. Ch. 112, § XII.B.1 (2008). Patient logs and written x-ray reports— permanently. 10-144 Me. Code R. Ch. 112, § XV.C.5 (2008).

Maryland Adult patients 5 years after the record or report was made. Minor patients 5 years after the report or record was made or until the patient reaches the age of majority plus 3 years (i.e., until patient turns 21), whichever date is later. MD. Code Ann., Health–Gen. §§ 4-403(a)–(c) (2008).

Adult patients 5 years after the record or report was made. Minor patients 5 years after the report or record was made or until the patient reaches the age of majority plus 3 years (i.e., until patient turns 21), whichever date is later. MD. Code Ann., Health–Gen. §§ 4-403(a)–(c) (2008).

Massachusetts Adult patients 7 years from the date of the last patient encounter. Minor patients 7 years from date of last patient encounter or until the patient reaches the age of 9, whichever is longer. 243 Mass. Code Regs. 2.07(13)(a) (2008).

30 years after the discharge or the final treatment of the patient. Mass. Gen. Laws ch. 111, § 70 (2008).

(continued)

A-71

 

 

 

 

 

 

 

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals* (continued)

State Medical Doctors Hospitals

Michigan 7 years from the date of service. Mich. Comp. Laws § 333.16213 (2008).

7 years from the date of service Mich. Comp. Laws § 333.20175 (2008).

Minnesota N/A Most medical records: Permanently (in microfilm). Miscellaneous documents: Adult patients 7 years. Minor patients 7 years following the age of majority (i.e., until the patient turns 25). Minn. Stat. § 145.32 (2007) and Minn. R. 4642.1000 (2007).

Mississippi N/A Adult patients Discharged in sound mind: 10 years. Discharged at death: 7 years.(2) Minor patients For the period of minority plus 7 years.(3)

Miss. Code Ann. § 41-9-69(1) (2008).

Missouri 7 years from the date the last professional service was provided. Mo. Rev. Stat. § 334.097(2) (2008).

Adult patients 10 years. Minor patients 10 years or until patient’s 23rd birthday, whichever occurs later. Mo. Code Reg. tit. 19, § 30-094(15) (2008).

Montana N/A(1) Adult patients Entire medical record—10 years following the date of a patient’s discharge or death. Minor patients Entire medical record—10 years following the date the patient either attains the age of majority (i.e., until patient is 28) or dies, whichever is earlier. Core medical record must be maintained at least an additional 10 years beyond the periods provided above. Mont. Admin. R. 37.106.402(1) and (4) (2007).

(continued)

A-72

 

 

 

 

 

 

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals* (continued)

State Medical Doctors Hospitals

Nebraska N/A Adult patients 10 years following a patient’s discharge. Minor patients (under 19) 10 years or until 3 years after the patient reaches age of majority (i.e., until patient turns 22), whichever is longer. Neb. Admin. Code 175 § 9-006.07A5 (2008).

Nevada 5 years after receipt or production of health care record. Nev. Rev. Stat. § 629.051 (2007).

5 years after receipt or production of health care record. Nev. Rev. Stat. § 629.051 (2007).

New Hampshire 7 years from the date of the patient’s last contact with the physician, unless the patient has requested that the records be transferred to another health care provider. N.H. Code Admin. R. Ann. Med 501.02(f)(8) (2008).

Adult patients 7 years after a patient’s discharge. Minor patients 7 years or until the minor reaches age 19, whichever is longer. N.H. Code Admin. R. Ann. He-P 802.06(h) (1994).(4)

New Jersey 7 years from the date of the most recent entry. N.J. Admin. Code § 13:35-6.5(b) (2008).

Adult patients 10 years following the most recent discharge. Minor patients 10 years following the most recent discharge or until the patient is 23 years of age, whichever is longer. Discharge summary sheets (all) 20 years after discharge. N.J. Stat. Ann. § 26:8-5 (2008).

New Mexico Adult patients 2 years beyond what is required by state insurance laws and by Medicare and Medicaid requirements. Minor patients 2 years beyond the date the patient is 18 (i.e., until the patient turns 20). N.M. Code R. § 16.10.17.10 (C) (2008).

Adult patients 10 years following the last treatment date of the patient. Minor patients Age of majority plus 1 year (i.e., until the patient turns 19). N.M. Stat. Ann. § 14-6-2 (2008); N.M. Code R. § 7.7.2.30 (2008).

(continued)

A-73

 

 

 

 

 

 

 

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals* (continued)

State Medical Doctors Hospitals

New York Adult patients 6 years. Minor patients 6 years and until 1 year after the minor reaches the age of 18 (i.e., until the patient turns 19). N.Y. Education § 6530 (2008) (providing retention requirements in the definitions for professional misconduct of physicians).

Adult patients 6 years from the date of discharge. Minor patients 6 years from the date of discharge or 3 years after the patient reaches 18 years (i.e., until patient turns 21), whichever is longer. Deceased patients At least 6 years after death. N.Y. Comp. Codes R. & Regs. tit. 10, § 405.10(a)(4) (2008).

North Carolina N/A Adult patients 11 years following discharge. Minor patients Until the patient’s 30th birthday. 10 A N.C. Admin. Code 13B.3903(a), (b) (2008).

North Dakota N/A Adult patients 10 years after the last treatment date. Minor patients 10 years after the last treatment date or until the patient’s 21st birthday, whichever is later. N.D. Admin. Code 33-07-01.1-20(1)(b) (2007).

Ohio N/A N/A

Oklahoma N/A Adult patients 5 years beyond the date the patient was last seen. Minor patients 3 years past the age of majority (i.e., until the patient turns 21). Deceased patients 3 years beyond the date of death. Okla. Admin. Code § 310:667-19-14 (2008).

Oregon N/A(1) 10 years after the date of last discharge. Master patient index—permanently. Or. Admin. R. 333-505-0050(9) and (15) (2008).

(continued)

A-74

 

 

 

 

 

 

 

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals* (continued)

State Medical Doctors Hospitals

Pennsylvania Adult patients At least 7 years following the date of the last medical service. Minor patients 7 years following the date of the last medical service or 1 year after the patient reaches age 21 (i.e., until patient turns 22), whichever is the longer period. 49 Pa. Code § 16.95(e) (2008).

Adult patients 7 years following discharge. Minor patients 7 years after the patient attains majority(5) or as long as adult records would be maintained. 28 Pa. Code § 115.23 (2008).

Puerto Rico N/A N/A(6)

Rhode Island 5 years unless otherwise required by law or regulation. R.I. Code R.14-140-031, § 11.3 (2008).

Adult patients 5 years following discharge of the patient. R.I. Code R. 14 090 007 § 27.10 (2008). Minor patients 5 years after patient reaches the age of 18 years (i.e., until patient turns 23). R.I. Code R. 14 090 007 § 27.10.1 (2008).

South Carolina Adult patients 10 years from the date of last treatment. Minor patients 13 years from the date of last treatment. S.C. Code Ann. § 44-115-120 (2007).

Adult patients 10 years. Minor patients Until the minor reaches age 18 and the “period of election” expires, which is usually 1 year after the minor reaches the age of majority (i.e., usually until patient turns 19). S.C. Code Ann. Regs. 61-16 § 601.7(A) (2007). See S.C. Code Ann. § 15-3-545 (2007).(7)

South Dakota When records have become inactive or for which the whereabouts of the patient are unknown to the physician. S.D. Codified Laws § 36-4-38 (2008).

Adult patients 10 years from the actual visit date of service or resident care. Minor patients 10 years from the actual visit date of service or resident care or until the minor reaches age of majority plus 2 years (i.e., until patient turns 20), whichever is later. See S.D. Admin. R. 44:04:09:08 (2008).

(continued)

A-75

 

 

 

 

 

 

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals* (continued)

State Medical Doctors Hospitals

Tennessee Adult patients 10 years from the provider’s last professional contact with the patient. Minor patients 10 years from the provider’s last professional contact with the patient or 1 year after the minor reaches the age of majority (i.e., until patient turns 19), whichever is longer. Tenn. Comp. R. & Regs. 0880-2-.15 (2008).

Adult patients 10 years following the discharge of the patient or the patient’s death during the patient’s period of treatment within the hospital. Tenn. Code Ann. § 68-11-305(a)(1) (2008). Minor patients 10 years following discharge or for the period of minority plus at least one year (i.e., until patient turns 19), whichever is longer. Tenn. Code Ann. § 68-11-305(a)(2) (2008).

Texas Adult patients 7 years from the date of the last treatment. Minor patients 7 years after the date of the last treatment or until the patient reaches age 21, whichever date is later. 22 Tex. Admin. Code § 165.1(b) (2008).(8)

Adult patients 10 years after the patient was last treated in the hospital. Minor patients 10 years after the patient was last treated in the hospital or until the patient reaches age 20, whichever date is later. Tex. Health & Safety Code Ann. § 241.103 (2007); 25 Tex. Admin. Code § 133.41(j)(8) (2008).(8)

Utah N/A Adult patients 7 years. Minor patients 7 years or until the minor reaches the age of 18 plus 4 years (i.e., patient turns 22), whichever is longer. Utah Admin. Code r. 432-100-33(4)(c) (2008).

Vermont N/A(1) 10 years. Vt. Stat. Ann. tit. 18, § 1905(8) (2007).

Virginia Adult patients 6 years after the last patient contact. Minor patients 6 years after the last patient contact or until the patient reaches age 18 (or becomes emancipated), whichever time period is longer. 18 Va. Admin. Code § 85-20-26(D) (2008).

Adult patients 5 years following patient’s discharge. Minor patients 5 years after patient has reached the age of 18 (i.e., until the patient reaches age 23). 12 Va. Admin. Code § 5-410-370 (2008).

(continued)

A-76

 

 

 

Appendix A — Overview and Detailed Tables

Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals* (continued)

State Medical Doctors Hospitals

Washington N/A Adult patients 10 years following the patient’s most recent hospital discharge. Minor patients 10 years following the patient’s most recent hospital discharge or 3 years after the patient reaches the age of 18 (i.e., until the patient turns 21) whichever is longer. Wash. Rev. Code § 70.41.190 (2008).(9)

West Virginia N/A N/A

Wisconsin 5 years from the date of the last entry in the record. Wis. Admin. Code Med. § 21.03 (2008).

5 years. Wis. Admin. Code Health & Family Services §§ 124.14(2)(c), 124.18(1)(e) (2008).

Wyoming N/A N/A(9)

* = All years are minimum periods (e.g., “at least” 7 years). Chart does not address retention of original x-rays or tracings, which may be subject to other requirements.

Minor = Person under 18 years old unless otherwise noted.

N/A = No statute or regulation found.

Notes: (1) No statutory or regulatory requirement but state medical board or medical association recommends as follows:

Alabama: At least 10 years. See “Medical Records,” available on the website of the Medical Association of the State of Alabama (MASA) at: http://www.masalink.org/uploadedFiles/Practice_Management/policy_Medicalrecords.pdf (accessed September 15, 2008).

California: Indefinitely, if possible. See CMA ON-CALL: The California Medical Association’s Information-On-Demand Service, available at http://www.thedocuteam.com/docs/retention_medicalrecords.pdf (accessed August 14, 2008).

Colorado: Adult patients 7 years after the last date of treatment and the records of minor patients 7 years after the last date of treatment or 7 years after the patient reaches the age of 18, whichever is later. See Colorado Board of Medical Examiners, Policy 40-7: “Guidelines Pertaining to the Release and Retention of Medical Records.” Available at: http://www.dora.state.co.us/Medical/policies/40- 07.pdf (accessed September 16, 2008).

Montana: Seven years from the date of last contact with the patient. Birth and immunization records: Until the patient’s 25th birthday. See Montana Board of Medical Examiners, Statement on Physician Obligation to Retain Medical Records (2004), available at http://www.mt.gov/dli/bsd/license/bsd_boards/med_board/pdf/patient_medrec.pdf (accessed July 17, 2008).

Oregon: In accordance with Oregon’s statute of limitations, at least 10 years after the patient’s last contact with the physician. If space permits, indefinitely for all living patients. See Oregon Medical Board, available at http://www.oregon.gov/OMB (accessed August 8, 2008).

Vermont: Patient’s lifetime if possible. Minors’ records: at least until the child reaches age 21 and decedent’s records at least 3 years after the patient’s death. See Vermont Guide to Health Care Law, available at http://www.vtmd.org/ (accessed September 16, 2008).

(2) If a patient dies in the hospital or within 30 days of discharge and is survived by one or more minors who are or claim to be entitled to damages for the patient’s wrongful death, the hospital must retain the patient’s hospital record until the youngest minor reaches age 28. Miss. Code Ann. § 41-9-69(1) (2008).

A-77

 

http://www.masalink.org/
http://www.thedocuteam.com/docs/retention_medicalrecords.pdf
http://www.dora.state.co.us/Medical/policies/40-07.pdf
http://www.dora.state.co.us/Medical/policies/40-07.pdf
http://www.mt.gov/dli/bsd/license/bsd_boards/med_board/pdf/patient_medrec.pdf
http://www.oregon.gov/OMB
http://www.vtmd.org/

 

 

 

Appendix A — Overview and Detailed Tables

(3) A person under the age of 21 is generally considered a “minor” in Mississippi. However, for purposes of consenting to health care, an “adult” is a person age 18 or older. See Miss. Code Ann. §§ 1-3-27 and 41-41-203(a) (2008).

(4) Hospital licensure rules have expired, but, as of June 2008, they were still in current use by the state Bureau of Licensing & Certification, which licenses health care facilities.

(5) The age of majority in Pennsylvania is 21. See 1 Pa. Cons. Stat. § 1991 (2008). However, minors over 18 may consent to health services in their own right. See 35 Pa. Cons. Stat. § 10101 (2008).

(6) Based only on statutes, not on regulations, which currently are published only in Spanish. (7) The period of election is the time during which a person may elect to bring a law suit for

malpractice that occurred while the patient was a minor, generally a maximum of 1 year after the minor reaches the age of majority. See S.C. Code Ann. § 15-3-545 (2007).

(8) The physician may not destroy medical records that relate to any civil, criminal, or administrative proceedings unless the physician knows the proceeding has been finally resolved. 22 Tex. Admin. Code § 165.1(b) (2008); Tex. Health & Safety Code Ann. § 241.103 (2007); 25 Tex. Admin. Code § 133.41(j)(8) (2008).

(9) Must maintain a record of a patient’s health care information: for at least 1 year following receipt of authorization to disclose that health care information; and during the pendency of a request for examination, copying, correction, or amendment of that health care information. Wash. Rev. Code § 70.02.160 (2008); Wyo. Stat. Ann. § 35-2-615 (2008).

A-78

 

  • Table of Contents
  • Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals*
  1. Applied Sciences
  2. Architecture and Design
  3. Biology
  4. Business & Finance
  5. Chemistry
  6. Computer Science
  7. Geography
  8. Geology
  9. Education
  10. Engineering
  11. English
  12. Environmental science
  13. Spanish
  14. Government
  15. History
  16. Human Resource Management
  17. Information Systems
  18. Law
  19. Literature
  20. Mathematics
  21. Nursing
  22. Physics
  23. Political Science
  24. Psychology
  25. Reading
  26. Science
  27. Social Science
  • Home
  • Blog
  • Archive
  • Contact
    • google+
    • twitter
    • facebook
Copyright © 2019 HomeworkMarket.com

The post Table A-7. State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospitals* appeared first on homework handlers.