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.
Examples of Patient Medical Records include, but are not limited to: diagnoses, doctor notes, intake forms, lab results, reports of services received, tests, and treatments.
Retain for 25 years past the date of service, then obtain state approval to dispose:
- All patient medical records.
Birth Certificate Worksheets
Birth Certificate Worksheets 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.
To be considered for permanent retention, see RIMS for guidance:
- All Birth Certificate Worksheets
Immunization and Vaccine Records
Immunization and Vaccine Records are a record of each patient's history of receiving immunizations and vaccines at the University of Illinois Medical Center.
To be considered for permanent retention, see RIMS for guidance:
- All Immunization and Vaccine Records
Patient Master Index File
Patient Master Index File consists of a chronological log per patient of each service provided.
To be considered for permanent retention, see RIMS for guidance:
- All Patient Master Index Files
Fetal Monitoring Records
Fetal Monitoring Records consist of the record of activity of a fetus immediately prior to birth.
Retain for 25 years from the date of birth, then obtain state approval to dispose:
- All Fetal Monitoring Records
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.
Retain for 10 years from date of service, then obtain state approval to dispose:
- Lists of persons or entities donating blood
- Lists of persons or entities receiving blood.
Retain for 75 years from date of attempted donation, then obtain state approval to dispose:
- Lists of persons permanently deferred from donating.
Blood Bank Training and Qualification Records
Blood Bank Training and Qualification Records consist of documentation indicating that employees have successfully completed the necessary training.
Examples of Blood Bank Training and Qualification Records include, but are not limited to: employee qualification records, employee training records, and blood born pathogens training required by OSHA.
Retain for 5 years past the date of training, then obtain state approval to dispose:
- All blood bank training and qualification records.
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.
Examples of Blood Bank Control Records include, but are not limited to: centrifuge calibration records, equipment checks and audits, as well as preventative maintenance records.
Retain for 10 years past date of calibration, performance check, or maintenance, then obtain state approval to dispose:
- Blood bank control records.
Imaging Services Records
Imaging Services Records include results from radiology and cardiology procedures and tests.
Examples of Imaging Services Records include, but are not limited to: EKG tracings, EEG tracings, EMG tracings, films, pictures, radiopharmaceutical tests, scans, slides, tapes, and test results.
Retain for 10 years past the date of service or procedure, then obtain state approval to dispose:
- Imaging Services records related to Mammograms.
Retain for 5 years past the date of service, then obtain state approval to dispose:
- All other Imaging Services Records.
Laboratory Records
Laboratory Records consist of laboratory procedures and documentation related to tests conducted on patient specimens.
Examples of Laboratory Records in this category include, but are not limited to: cytology slides, histopathology slides, lab test requisitions, laboratory procedures, laboratory quality control documents, laboratory reports, pathology logs, records of blood draws, and specimen records.
Retain for 5 years past the date of service, then obtain state approval to dispose:
- Lab Test Requisitions
- Non-clinical lab studies records
- Specimen records.
Retain for 10 years past the date of service, then obtain state approval to dispose:
- All other Laboratory records.
Pharmacy Records
Pharmacy Records consist of documents relating to dispensing, administering, acquiring, and verifying prescriptions of controlled medicinal substances.
Retain for 3 years past the date of dispensing, then obtain state approval to dispose:
- Acquisitions order forms
- Receipts for dispensing narcotics
- Records for administering narcotics.
Retain for 5 years past the date of dispensing, then obtain state approval to dispose:
- Facsimile copy of a prescription
- Records of prescriptions dispensed
- Written memorandum of the oral prescription.
Retain for 5 years past prescription refill verification, then obtain state approval to dispose:
- Prescription refills
- Verification log of schedule III and IV controlled substance prescription refills.
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.