Record Retention

All UBMD employees must ensure that PHI is available to meet the needs of continued care, legal requirements, research, education, and other legitimate uses.

UBMD employees should follow the following record retention guidelines to meet the needs of our patients, providers, regulatory and accreditation requirements:

  • For adults, clinical records must be maintained for a minimum of seven (7) years from the last contact with the patient.
  • For minors and obstetrics, clinical records must be maintained through the age of twenty-one (21) of the child, or seven (7) years from the last date of service, whichever is longer.
  • Patient billing records must be maintained for seven (7) years.  This includes maintenance of superbills, inpatient/outpatient/surgery charge cards, cash and credit card payment logs and copies of checks.  Paper superbills that are added electronically do not need to be maintained.
  • For deceased patients, clinical records must be maintained a minimum of 6 years after death.
  • The record’s retention requirement should be measured from the date of the last professional contact with the patient to determine the length of time the record is required to be retained.
  • An electronic scan of the entire paper record will meet the retention requirement, provided the technology to access the record is maintained for the applicable period of time.
  • In the event a patient files a lawsuit against UBMD, records should be maintained until the lawsuit is resolved. 
  • Under the False Claims Act, claims may be brought up to six (6) years after the incident; however, on occasion, the time has been extended to ten (10) years.