UTMB HANDBOOK OF OPERATING PROCEDURES

Section 9 Clinical Policies Subject 9.2 Patients’ Records Policy 9.2.14 Medical Record Retention

04/15/96- Originated 04/06/09- Reviewed w/ changes 12/14/98 –Reviewed w/o changes Health Information Management -Author

Medical Record Retention

Policy

The University of Texas Medical Branch at Galveston (UTMB) permanently retains medical records for purposes of patient care, student training, clinical research and to meet legal requirements. The Health Information Management Department (HIM) is responsible for maintaining these records regardless of medium type. This includes all microfilm, paper, or electronic computer-based systems that may be retired because of improved systems operations, or a conversion to alternate application. The exception to this rule is medical records transferred to UTMB from the purchase of a hospital or clinic external to the university or that have otherwise been acquired by UTMB. For these acquired medical records, which contain Protected Healthcare Information (PHI) that is not identified by UTMB abstracting or coding systems, the state retention regulation will be followed.

References

Texas Health and Safety Code: Section 241.103 IHOP Policy 9.2.13, UTMB Medical Record Policy