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Texas Department of State Health Services Retention Schedule for Medical Records (Guideline for Doctors' Offices and Clinics)

Texas Department of State Health Services Retention Schedule for Medical Records
(Guidelines for Doctors' Offices and Clinics)*

*Medical records in the DSHS hospitals (with different retention periods based on Health and Safety Code Title 4, §241.103; Health and Safety Code Title 7, §595; and Health and Safety Code Title 7, §611) are found  at  Mental Health Hospitals (pdf format 48KB); Texas Center for Infectious Disease (pdf format 111KB); and Rio Grande State Center (pdf format 93KB)

The Texas Medical Board (www.tmb.state.tx.us) has authority to license and regulate the records of physicians in the State of Texas.  The State Board of Dental Examiners (www.tsbde.state.tx.us) has the authority to license and regulate the records of dentists in the State of Texas.  The retention periods are posted here as a convenience to the professional staff who maintain medical records for the Texas Department of State Health Services and are not intended to take the place of the instructions that private practice physicians, clinics, and dental offices should receive from those authorizing agencies.

Record Type

Minimum Retention Period
(Based upon age as last date of service.)

I. Program Medical Records

Adult Health

Child Health

Chronically Ill & Disabled Children

Family Health (See footnote 1)

Family Planning (See footnote 2)

Maternal Health (See footnote 3)

Sexually Transmitted Diseases (See footnote 4)

HIV/AIDS (Exceptions see footnote 5)

Tuberculosis (See footnote 6)

Communicable Diseases

7 years past the last date on which service was given or until the patient's 21st birthday, whichever occurs later.  (22 TAC 165)  

Dental Records

Dental Referrals

5 years (22 TAC 108.8)
Hansen's Disease (See footnote 7) permanent retention period
II. Immunization Records & Forms (See Footnote 8)

Adults: 10 years following end of calendar year in which the form was signed.

Minors: 21st birthday or 10 years following end of calendar year in which form was signed, whichever occurs later. 

III. Screening Procedures

Health Risk Appraisals

Blood Pressure Screening

Blood Pressure Referral

HIV (Exceptions see footnote 5)

Diabetics Screening

Other Laboratory Screenings & Tests

7 years past the last date on which service was given or until the patient's 21st birthday, whichever occurs later.  (22 TAC 165)  
Vision and Hearing (See Footnote 9) 7 years past the last date on which service was given or until the patient's 21st birthday, whichever occurs later. (25 TAC 37.23)
Infant Screening for Genetic or Metabolic Disorders Until the patient's 21st birthday.
IV. Other

Short Term Records

Retain as medical records, following guidelines for the specific program with which the record is associated.

Master Patient Index
Permanent retention period
Communicable Disease Surveillance Forms completed by TDH/DSHS personnel (See footnote 10) 7 years past last date encounter occurred or until patient's 21st birthday, whichever occurs later.
Special Projects, Research, Etc. 10 years or as designated at the time the project is implemented.
Women, Infants, Children (WIC) (See footnote 11) 3 years following the date of the submission of the final expenditures report for the period to which the report pertains (See Footnote 8)
Financial Records relating to program services (See footnote 12)

Minimum of 5 years from date of service or until all audit questions, appeal hearings, investigations, or court cases are resolved. 

[as recorded in TSL Local Schedule HR:  “by regulation – Medicare Hospital Manual, HIM-10, Sec. 413 (B) –Rev. No. 572” and 1 TAC 354.1004

Footnotes

(1) If records of several family members are located in same file, recommendation is based upon age of youngest family member.

(2) (a) Title XX records should be kept 7 years past the date of services or until the 21st birthday, whichever occurs later.

     (b) The retention period of records that show use of an I.U.D. will begin to run at the end of the effective life of the I.U.D.

      (c) The retention period of records that show the surgical implantation of contraceptives will begin to run when the contraceptive is exhausted.

(3) All maternal health records must be retained for 7 years past the last date of service, until the mother's 21st birthday, or until the infant's 21st birthday, whichever occurs later.

(4) All sexually transmitted disease records containing positive syphilis test results including congenital syphilis must be maintained until 7 years past the death of the patient, if known, or 18 years from the last date of service. Sexually transmitted disease medical records other than positive syphilis tests must be kept 7 years past the last date of service or until the patient's 21st birthday, whichever comes later. All sexually transmitted disease intervention records, including investigations, interviews, and disease intervention case management notes must be kept 3 years past the last date of service or until the patient's 21st birthday, whichever comes later.

(5) (a) Prevention counseling notes, risk reduction plans, and case management records compiled on HIV-positive adult clients must be maintained for 7 years past the last date of service or patient's death, if known. For HIV-positive children, the records must be kept for 3 years after the 21st birthday, even in death, or 7 years, whichever comes later.

      (b) CD4 online management patient information system (Compis) reports generated from the database must be kept as long as they are administratively valuable. CD4 online management patient information system (Compis) database records are kept for 3 years past the end of the Ryan White Title II contract period.

      (c) HIV/AIDS disease intervention records, including investigations, interviews, and disease intervention case management notes must be kept 3 years past the last date of service or until the patient's 21st birthday, whichever comes later.

      (d) HIV-positive anonymous test results (includes serology, counseling notes, risk reduction plan, and prevention case management notes must be maintained 1 year past the test date or last date of service, whichever comes later. HIV-negative anonymous test results including serology, counseling notes, and risk reduction plan are retained for 90 days after test date, or, the results are given to the client, whichever comes first.

     (e) HIV-positive confidential test results including serology and medical records must be maintained for 7 years after the patient's death, if known, or 18 years from the last date of service. HIV-negative confidential test results, including serology, counseling notes, and risk reduction plan are maintained 7 years past the last date of service or until the patient's 21st birthday, whichever comes later.

(6) X-rays showing significant abnormalities may be given to the patient and/or another authorized person. Unclaimed x-rays will be returned to program managers for disposition.

(7) Records are of research significance and must be maintained permanently.

(8) When using the C-100 Form, it is not necessary to retain the Vaccine Information Materials.

(9) Vision and Hearing screenings are mandated to take place every other year from pre-kindergarten through 7th grade.  

(10) Original vaccine-preventable disease surveillance forms for the following diseases: measles, mumps, rubella, congenital rubella syndrome, tetanus, pertussis, hepatitis B, diptheria, polio, varicella, and hib Type B should be sent to the Infectious Disease Control Unit. Disease surveillance forms for other reportable infectious diseases including tuberculosis, hepatitis A, hepatitis C, Rocky Mountain Spotted Fever, Lyme Disease should be sent to Infectious Disease Control Unit.

(11) Financial records and documents must be retained for a minimum of 3 years following the date of the final expenditure report for the period to which the reports pertain, with the following qualifications:

      (a) Records must be retained beyond the 3-year period if audit findings have not been resolved.

      (b) Records for nonexpendable property must be retained for 3 years after its final disposition.

      (c) If lab screening is done in connection with specific program, e.g., family planning, maternity, etc., data on lab report must be kept with the program record and retained until the record is destroyed.

(12) Remittance and Status Reports and claims to fully document services and supplies provided to a Medicaid client must be made available promptly upon request from the Texas Department of State Health Services, Texas Attorney General's Medicaid Fraud Control Unit, NHIC, Department of Family and Protective Services, and Representatives of the federal Department of Health and Human Services. 

PAPER RECORDS MUST BE DESTROYED BY SHREDDING.
MICROFILM RECORDS MUST BE DESTROYED BY PULVERIZATION.
ELECTRONIC RECORDS MUST BE DELETED. 
CONFIDENTIALITY MUST BE MAINTAINED EVEN IF OUTSIDE CONTRACTORS ARE USED.

TEXAS DEPARTMENT OF STATE HEALTH SERVICES (11/8/2008)
Last updated October 01, 2012