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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

Division of Regulatory Affairs (DRA)
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Records Management: Schedule 3. Professional Services


INDEX

SCHEDULE 3. PROFESSIONAL SERVICES

SECTION

  1. (VACANT)
  2. Dental Services
  3. Medical Records
  4. Nursing Services
  5. Nutrition and Dietetics
  6. Laboratory Services (Including Radiology)
  7. Pharmacy
  8. Social Work Services
  9. Eye Care Program
  10. Preventive Health
  11. Environmental Health
  12. Health Education
  13. Maternal and Child Health
  14. Mental Health Programs
  15. Physical Therapy
  16. Community Health Representative Program
  17. Emergency Medical Services
  18. Alcoholism/Substance Abuse Program
  19. Urban Indian Health Program
  20. Audiology and Speech Pathology
  21. Nuclear Medicine

IHS RECORDS SCHEDULE 3. PROFESSIONAL SERVICES

THIS SCHEDULE PROVIDES GUIDELINES FOR RECORDS OF POLICIES, RESPONSIBILITIES, STANDARDS AND PROCEDURES WHICH GOVERN THE MEDICAL AND PROFESSIONAL ACTIVITIES OF THE IHS.

SCHEDULE 3.  PROFESSIONAL SERVICES

SECTION 1 - (VACANT)
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

1-1

RESERVED

 

SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 2 - DENTAL SERVICES
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

2-1

 

BENEFICIARIES LEDGER RECORD FILES. Ledger used to identify the removable dental appliances when removed from mouths of patients at time of admission and to indicate beneficiary's name, number and type of appliance.

Destroy 1 year after date of last entry.

2-2

DENTAL APPOINTMENT RECORD FILES. Ledger or book indicating daily appointments for patients for dental treatment and showing patient's name, time of appointment and type of work to be performed.

Destroy 1 year after date of last entry.

2-3

DENTAL LABORATORY REQUISITION AND WORK RECORD FILES. Copies of instruction sheets to obtain fabrication of dental appliances from central dental laboratory and related material.

Destroy after patient's case is completed.

2-4

 

DENTAL MASTER CARD FILES.  Detailed summary of dental services rendered to a patient in an IHS health care facility; used as a ready reference for budget purposes, and for compiling statistics on patients treated.

Destroy 3 years after date of last activity.

2-5

DENTAL CARD INDEX FILES.  Dental service index cards indicating patient's name, diagnoses, treatment, condition, etc., on current or recent patients receiving dental treatment.

a. If patient was not examined.

b. If patient was examined but not treated.

c. If patient was treated or received x-rays.

a. Destroy when patient is discharged.

b. Destroy 6 months after discharge.

c. Destroy when 3 years old.

2-6

 

DENTAL X-RAY FILM FILES. Dental x-ray film exposed.

a. Dental x-rays filed in Outpatient Treatment Folder or in Medical Records File.

b. Copies of dental x-rays used for research and teaching purposes which are not filed in the patient's record.

c. All other original dental x-rays maintained at HIS health care facilities.

d. Facsimile reproduction of dental x-rays.

a.  Destroy when purpose has been served. Retirement to the FRC is not authorized. If filed with the Patient Medical Record, the x-ray must be removed before transfer.

b. Destroy when purpose has been served.

c. Destroy 3 years after the date of last exposure.

d. Destroy when purpose has been served.

2-7

LABORATORY CASE LOAD LEDGER FILES. Ledger used to record all cases handled by the dental laboratory and to indicate date of receipt, name of patient, referring facility, laboratory case number, and description of case.

Destroy 1 year after date of last entry.

2-8

PRECIOUS METALS LEDGER FILES.  Ledgers contain a record of dates precious metals were received from supply service, the combined gross troy weight of all gold received (excluding fabricated bars) and the number of prefabricated gold bars received.  Date, name of patient and description of patient and description of each appliance fabricated.  Weight of platinum received, and gross weight of all gold turned over to supply service.  Unserviceable gold appliances retained by patients along with their signature.

Destroy 3 years after date of last entry.

2-9

PRECIOUS METALS ISSUE SLIP FILES.  Copies of memoranda indicating amount of gold turned in to supply service.

Destroy after 1 year.

2-10

OLD GOLD TURN-IN FILES.  Correspondence and related papers on old gold turn-in.

Destroy after 1 year.

2-11

PRECIOUS METALS RECORD CARD FILES. Cards indicating a running record of each type of precious metal on hand and showing the amount issued and the balance on hand at all times.

Destroy 1 year after card has been filled and the balance brought forward to new card.

2-12

DENTAL DATA REPORTS.  Computer generated reports of services provided.

Destroy after 1 year.

2-13

WATER FLUORIDATION REPORTS.  Computer generated reports to monitor community water fluoridation activities.

Destroy after 1 year.

SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 3 - MEDICAL RECORDS
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

3-1

MEDICAL RECORDS FILE.  This record series contains all professional and administrative material necessary to document the episodes of medical care and benefits provided to individuals by the IHS health care system.  It completely documents diagnostic examinations and definitive medical, surgical, psychiatric, and dental care or treatment rendered a patient at an IHS health care facility.  It contains, in written and graphic form, the diagnostic, treatment and sociological information compiled by various members of the medical care team who participated in the care of a patient during one or more courses of treatment.  It contains documentation of the patient's legal eligibility for IHS medical benefits and the administrative documents relating to various episodes of hospital, nursing home, domiciliary, or outpatient care furnished at IHS health care facilities.  In addition, it is intended to meet the legal, administrative, teaching, and research needs of the IHS medical staff, and provide a means of studying and evaluating the type of care rendered or other monetary benefits available.  Also includes clinical records of the deceased.

Retain in IHS health care facility from 3 to 7 years after the last episode of care.  Records may be retired to the FRC after 3 or more years of inactivity (depending on a facility's availability of filing space and research activities.)  Destroy 75 years after date of last activity.

NOTE:  If the Medical Records are transferred to a micrographic format, the original Medical Records should be destroyed after verification of the quality of the microform.  Microform creation and verification procedures should conform with the provisions of 36 CFR 1230.  The records should be destroyed by shredding within 10 working days of the verification of the microfilm.

PCC data entry forms:  The original (white) copy will be files in the PMR.  The pink copy is the data entry form.  The yellow copies are used at the discretion of the facility.  All documents used as data entry forms for the PCC system, with the exception of the pink copy, will be maintained for one year, or when no longer needed to reconstruct the master-file, whichever is sooner.

3-2

TUMOR REGISTRY FILES (INDEX CARD AND FOLDER FILES).  Information on patients treated for tumors.  It contains abstracts of inpatient information from the Medical Records File, subsequent follow-up data (including that from private sources) and related material.  This file is used for treatment purposes as well as research.

Transfer to the FRC after 5 years of inactivity. Destroy when 75 years old.

3-3

PATIENT LOCATOR FILES.  Locator card containing basic identification data for each patient admitted to the health care facility or treated on an outpatient basis.

Destroy upon discharge of patient.

3-4

MASTER PATIENT INDEX (MPI) FILES.  A permanent MPI maintained by each facility containing the patient's basic identification data for each patient registered at each facility.

PERMANENT. Cut off on death of individual or transfer of individual to another services area. Transfer to FRC when at least 1 cubic foot accumulates. Transfer to the National Archives when 20 years old.

3-5

ADMISSION LOG FILES.  Records of chronological admission log sheets.

Destroy when 6 months old.

3-6

ADMISSIONS AND DISCHARGES FILES.  Daily patient admission and discharge sheets.

NOTE:  A master set will be maintained to contain a copy of each admission and discharge sheet created during the latest 12-month period.

Cut off master set annually. Destroy when 1 year old. Destroy all other copies after purpose has been served.

3-7

BENEFICIARIES EFFECTS AND VALUABLES AUDIT FILES.  Records of audits of effects, valuables, Government-issued clothing, incidentals and related records.

Destroy 1 year after completion of subsequent audit and resolution of all discrepancies. If no audit is done, destroy when 1 year old.

3-8

DISPOSITION DATA FILES. Mechanically prepared listings (code sheets) of discharged patients' records which have been prepared for entry in a processing Master Patient File and related material.

Destroy 1 year after a master record has been created at the Data Processing Center.

3-9

ERROR DATA FILES. Mechanically prepared listings of discharged patient's records which have been rejected as unacceptable to the inpatient data systems.

Destroy after the errors have been corrected and resubmitted data validated and after the listing used for quality control purposes have been exhausted or destroy when no longer needed, whichever is sooner.

3-10

DIAGNOSTIC AND OPERATION INDEX FILES.

a. Mechanically prepared listing of coded diagnostic and operative data of discharged patients.

b. Previous manually prepared diagnostic and operative indexes and locally approved special inpatient diagnostic and operative indexes.

a. Destroy monthly listing after receipt of consolidated biannual listing.

b. Destroy consolidated biannual listing or prior equivalent 20 years after date of report, or after purpose has been served, whichever is sooner.

3-11

APPOINTMENT BOOK FILES.  A listing of appointments given to patients.

Destroy 6 months after last entry.

3-12

PATIENTS ACCOUNT FILES.  Patient account cards, patient ledger cards; microfilm and paper record reports of patient funds and all related material.

Destroy 5 years after final withdrawal of appropriate disposition of all monies.

3-13

ELECTROCARDIOGRAPH (ECG) TRACING FILES. Includes phonocardiograms, echocardiographies, nuclear cardiac scans and vector-cardiograms.  This series of records consists of ECG tracings maintained in the patient's Medical Records File.  The tracings maintained in the patient's Medical Records File consists of cut out portions of the original tracings which are filed with the electrocardiograph report, SF 520.  Clinic copies consist of reproductions or photocopies of the original tracings.

  1. ECG Tracings
    1. File cut out portions in the patients' Medical Records File along with the ECG Report, SF 520.
    2. Residue of the original tracings, i.e., portions of the original tracings not required for filing in the Medical Folder.
    3. Copies of tracings retained in the Cardiology Clinic.
    4. Microfilm of tracings master and one positive copy microfilm will be inspected every 2 years for quality.

Cut off when book is full.  Transfer to the FRC when 5 years old.  Destroy  10 years old.

(1)  See Medical Records File.

(2)  Destroy immediately.

(3)  Convert hard copy to microfilm after 3 years. Destroy hard copy upon verification  that the microfilm is an adequate substitute for the hard copy.

Destroy 22 years after the creation of the microfilm.  (Refer to Supply Center for destruction and recovery of silver.)

3-14

ELECTROENCEPHALOGRAPH (EEG) TRACING FILES.  Record series consists of records of patients with neurological and psychiatric disorders and is used for the purpose of examination and treatment.

a. EEG Tracings.

b. Microfilm Tracings.

c. Electroencephalographic Request and Report.

d. EEG Report.

 (1) Hard copy original.

 (2) Hard copy duplicate.

(3) Microfilm duplicate master and one positive copy.

a.  Maintain in EEG Clinic.  Convert to microfilm when 5 years old.  Destroy hard copy after conversion to microfilm and after verification that microfilm is an adequate substitute for the hard copy.

b. Microfilm, master and one positive copy. Maintain in EEG Clinic.  Destroy 25 years after creation of microfilm.

c. Destroy when 1 year old.

(1) File in patient's Medical Records File.

(2) Maintain in EEG Clinic. Convert to microfilm when 5 years old.  Destroy after conversion to microfilm and after verification that the microfilm is an adequate substitute for the hard copy records.

(3) Maintain in EEG Clinic.  Destroy 25 years after creation of the microfilm. Inspections of the microfilm for quality take place every 2 years.

3-15

TUBERCULOSIS CASE REGISTER CARD FILES. Inactive tuberculosis case register cards.

Destroy inactive cards after 2 years.

3-16

OPERATION LOG FILES.  Operation logs which indicate type of operation, surgeon, assistant, scrub nurse, sponge count, anesthetist, agent, method, pre-op, diagnosis, post op, diagnosis, complications, etc.  The log book is forwarded by Nursing personnel to the Medical Records Department when the log book is full.

Destroy 10 years after receipt in Medical Records Department.

3-17

SCHEDULE OF OPERATIONS FILE. Daily schedule of operations.

Destroy when 3 months old.

3-18

FETAL MONITOR STRIPS.

Cut off annually. Retain in IHS health care facility from 3 to 7 years after the last episode of care. Records may be retired to the FRC after 3 or more years of inactivity (depending on a facility's availability of filing space and research activities.) Destroy 25 years after date of last activity.

3-19

PATIENT SIGN IN SHEETS. Patients sign in clinic.

Destroy when 6 months old.

3-20

EMERGENCY ROOM (ER) LOG FILES.  A log maintained by the ER personnel containing adequate patient identification; information concerning time and method of patient's arrival and by whom transported; pertinent history of injury or illness, including details relative to first aid or emergency care given prior to patient's arrival at the facility; description of significant clinical laboratory and radiological findings; diagnosis and treatment given; condition of patient on discharge or transfer; final disposition, including instructions given to the patient and/or "significant other."  The log is forwarded by Nursing personnel to the Medical Records Department when the log book is full.

Transfer to the Medical Records Department when book is full.  Transfer to the FRC when 5 years old.  Destroy when 10 years old.

3-21

DELIVERY ROOM OBSTETRICS (OB) LOG FILES.  A delivery log maintained by the nursing OB ward. The log is forwarded by Nursing personnel to the Medical Records Department when the log book is full.

Cut off when book is full.  Transfer to the FRC when 5 years old.  Destroy when 10 years old.

SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 4 – NURSING SERVICES
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

4-1

24-HOUR REPORT FILES.  24-hour report of patient's condition and nursing unit activities.

Destroy when 45 days old.

4-2

ALCOHOL AND NARCOTICS RECORDS FILE. Alcohol and narcotics records where all items were dispensed on the ward.  Alcohol and narcotics inventory and certification records.

Destroy when 2 years old.

4-3

COMMUNITY NURSING PROGRAM FILES. Copies of nursing care referral forms, copies of requests for community home nursing care, and related material.

Destroy when 30 days old.  NOTE:  The copy returned from the community home nursing staff is filed in the patient's Medical Records File.

4-4

DETAIL SHEET FILES.  Detail sheets for identifying closed ward patients upon departure and return to ward.

Destroy daily after patients have been accounted for.

4-5

MEDICATION CARD FILES.  Cards indicating types of medicines ordered for physicians and used by nurses for reference in preparation, administration, and recording of the medication.

Destroy after medicine is discontinued.

4-6

NURSING CARE PLAN FILES.  Nursing Care Cards.

File in Medical Records File.  Destroy in accordance with Schedule 3, item 3-1.

4-7

PATIENT COUNT FILES.  Patient count forms used to identify ward patients at close of tour of duty.

Destroy when 90 days old.

4-8

PROCEDURE CARD FILES.  Cards outlining care and treatment for certain diseases and conditions.

Destroy when superseded.

4-9

DAILY ASSIGNMENT FILES.  Daily assignments of Nursing Service personnel.

Destroy after 30 days.  NOTE: For purposes of workload projection, equity of overtime distribution and work schedules, records may be retained up to 1 year at the discretion of the head nurse.

4-10

INFORMATION DATA FILES.  Information data cards showing tours of duty, absenteeism, and assignments.

Forward to Personnel  Division for inclusion in the OPF upon separation or transfer of employee.  GRS 1/6

4-11

TOUR OF DUTY RECORDS FILE.  Tour of duty records of Nursing Service personnel.

Destroy when 30 days old.

4-12

PATIENT'S CLOTHING AND VALUABLES FILE. Beneficiaries effects slip, temporary withdrawals, inventory of funds and effects patient's clothing account, patient's effect slips, patient's valuable and miscellaneous effects account, requests for Government-issued clothing, receipts for packages, requests and instructions, redisposition of unserviceable and excess clothing and articles, and patient's valuables inventory envelope.

Destroy 6 months after discharge of patient and after proper accountability of all items.

SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 5 - NUTRITION AND DIETETICS
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

5-1

RECEIPT FILES. Field service receipts or equivalent and related material.

Cut off annually.  Destroy at close of fiscal year.

5-2

COST ACCOUNTING FILES.  Source documents for dietetic cost accounting of subsistence items including all necessary cost control records to insure that all transactions affecting the fiscal account are accurately represented.

Destroy after 6 months or when no longer required for reconciliation or informational purposes.

5-3

COST ANALYSIS FILES. Food cost analyses; i.e., analysis of price trends, usage studies, selected food items and any other analytical food cost studies.

Cut off at close of fiscal year.  Destroy when 3 years old or when no longer needed for informational value, whichever is sooner.

5-4

MEAL TICKET FILES (PATIENT). Patient meal ticket or equivalent.

Return to Area Office at the end of each month for financial control after required reports have been prepared.

5-5

MEAL TICKET FILES (EMPLOYEE).  Employee subsistence passes (full and partial), individual meal authorizations and related material.

Return to Area Office at the end of each month for financial control after required reports have been prepared.

5-6

RATION CONTROL FILES.  Ration control records of meals served (patient, employee, guest, etc.) and costs and related material.

Destroy when 1 year old.

5-7

DIET FILES.  Records of various diets; i.e., regular, bland, high protein, special, daily routine, etc., and related material.

Destroy when obsolete or when no longer of value for reference.

5-8

DIET PRESCRIPTION FILES.  Diet and equivalent orders issued by physicians.

Destroy when 3 months old.

5-9

MENU FILES.  Menu records and related material issued daily, weekly, routinely, selectively, etc.

a. A 1-year complete set of corrected originals will be maintained.

b. All other copies and all other records.

a. Destroy after close of next succeeding year.

b. Destroy after purpose has been served.

5-10

RECIPE FILES.  Recipes of all types and kinds; standard, tested, etc., and related materials.

Destroy when obsolete or when no longer needed

5-11

PATIENT EDUCATION FILES.  Dietetic training material for patients, diet instructions, diet lists, special instructions for individuals and groups of patients.

Destroy when obsolete or when no longer of training value.

SCHEDULE 3.  PROFESSIONAL SERVICES

SECTION 6 – LABORATORY SERVICES (INCLUDING RADIOLOGY)
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

6-1

AUTOPSY PROTOCOL FILES. Copies of autopsy protocols.

Cut off when superseded or obsolete. Destroy the Department's copy when 2 years old. File original copy in patient's Medical Records File.

6-2

BLOOD BANK MONITORING FILES (CARD). Cards indicating daily records of blood inspections, daily records of refrigerator temperatures, records of bacteriologic studies, and records of disposition of unused blood.

Destroy when 5 years old.

6-3

BLOOD DONOR FILES. Blood donor registration cards and related cross index cards indicating blood group and type.

Destroy 5 years after last donation.

6-4

BLOOD ISSUE FILES. Log book containing names of authorized persons to which blood was issued and a record of reissued blood.

Destroy 10 years after date of last entry.

6-5

BLOOD SOURCE LOG BOOK. A log book indicating source from which blood was received; i.e., donor, Red Cross, contract blood bank, etc.

Destroy 5 years after date of last entry.

6-6

BLOOD TRANSFUSION REQUEST AND RECORD FILES. Copies of the clinical record - blood transfusion indicating blood grouping, typing and compatibility tests.

File original in patient's Medical Department's copy Records File. Destroy the when 5 years old.

6-7

LABORATORY METHODS FILE. Cards indicating approved methods and procedures for conducting various laboratory tests.

Cut off when superseded, obsolete, or rescinded. Destroy when 5 years old, or when no longer needed for administrative purposes, whichever is sooner.

6-8

LABORATORY REPORTS FILE.

a. Patient section - copies of the clinical record – laboratory reports on patients.

b. Other than patient section - copies of the clinical record - laboratory reports used for examination of individuals other than patients, such as blood donors.

a. File original copy in patient's Medical  Records File.  Destroy the Department's copy when 2 years old.

b. Destroy whentd>

6-9

MORGUE RECORDS FILE.  Daily record of morgue refrigerator temperatures and copies of reports of inspection of morgues.

Destroy when 1 year old.

6-10

TISSUE EXAMINATION RECORDS FILE.  Reports of tissue examinations, pathological reports, paraffin blocks, and all clinical lab tests, performed on patients.

File original reports in patient's Medical Records File.  Destroy Department's copy when 7 years old.

NOTE: Medical specimens are not authorized for filing in the PMR.  Maintain separately and destroy in accordance with the Department's copy of the reports.

6-11

CYTOLOGY SPECIMEN FILES.  Slide specimens and reports (i.e., pap smears).

File original reports in patient's Medical Records File.  Destroy Department's copy when 5 years old.

NOTE: Medical specimens are not authorized for filing in the PMR.  Maintain separately and destroy in accordance with the Department's copy of the reports.

6-12

RADIATION MONITORING FILES.  Reports of findings, test reports and analyses, film badge reports, protection surveys, radiation exposure reports, reports of meter monitoring, related and similar material properly filed.

a. Employee records.

b. General subject records.

a.  Destroy 1 year after separation or transfer    of employee.

b.  Cut off annually.  Destroy when 5 years old.

6-13

RADIUM AND RADON CONTROL FILES. Shipment control records of radioactive substances and related materials.

Destroy when 2 years old.

6-14

PATIENT THERAPY FILES (RADIOLOGY SERVICE). Copies of treatment course records, therapy summaries, progress notes, technical factors (applied) and related material.

File original copy in patient's Medical Records File.  Destroy the Unit's copy when 3 years old.

6-15

PATIENT (TUMOR) TREATMENT CONTROL CARD FILES.  Individual cards maintained by name of patients as a tumor master record and which are used as a pathological index to and summary of patients treated; used for treatment, teaching and research purposes.

Place in an inactive file when patient is no longer under treatment or in follow-up program.  Cut off inactive file annually. Destroy when 10 years old.

6-16

X-RAY FILM INVENTORY FILES.  Stock control records showing the size, the number of x-ray films received, the number used, and the current balance on hand.  Film that is almost outdated or expired should be exchanged before the film becomes outdated.

Destroy after 1 year and after films have been accounted for.

6-17

X-RAY ALPHABETICAL INDEX FILES (ACTIVE AND INACTIVE SECTION).  Cards used as cross reference and locator to x-ray film files.

Destroy when corresponding x-ray films are destroyed.

6-18

X-RAY FILM FILES (GENERAL).

a. Patient x-rays (except as noted under item b below).

b. Patient x-rays in the following categories: tuberculosis patients, patients and children with chronic diseases, and all mammography.

c. X-rays that are unserviceable, unidentifiable, or otherwise unusable for diagnostic purposes because of faulty exposure or processing, cloudiness, discoloration, breaking, general deterioration, or unclear name and/or number of the patient.

d. Copies of x-ray interpretations which are filed with the x-rays. Original interpretations are filed in the patient's Medical Records File.

a.  Destroy 5 years after date of last exposure, and after a report has been filed in the patient's Medical Records File.

b. Keep 2 prior x-rays for comparison purposes, regardless of age. Destroy the oldest x-ray when there are 4 x-rays in the file. Cut off file on death or transfer of patient to another service area. Destroy when 5 years old.

c. Destroy immediately.

d. Destroy when x-ray is destroyed.

6-19

X-RAY FILM FILES (TEACHING).  Exposed x-ray films of special interest and those that have exceptional teaching value.

Destroy when no longer of value for teaching and educational purposes.

6-20

X-RAY PATHOLOGICAL INDEX FILES.  Cards indexing special and interesting roentgen logical entities.

Destroy when no longer of medical reference value or when card is replaced.

6-21

X-RAY REGISTER FILES.  Record of x-ray numbers assigned, films used and type of examinations.

Destroy 10 years after date of last entry in each bound volume.

6-22

DAILY LOG SHEETS.  Single sheets for logging x-rays.

Destroy when 1 year old

6-23

DAILY IMAGING SCHEDULE SHEETS.  X-ray, Ultra Sound, and Computerized Topography, etc.

Destroy when 1 year old

6-24

MONTHLY STATISTIC SHEETS FILE.

Destroy when 5 years old

6-25

ANATOMIC PATHOLOGY.  Slides, paraffin blocks, tissue examination records, and tissue examination reports.

File original reports in the patient's Medical Records File. Destroy the unit's copy when 2 years old.

NOTE: Medical specimens are not authorized for filing in the PMR. Maintain separately and destroy in accordance with the Department's copy of the reports.

6-26

LABORATORY SERVICE FILES.  All quality control, accession logs/registers, proficiency test reports, work load statistics, records of lot numbers of control and reagents and similar documents for recording dates and other information related to laboratory testing.

Destroy when 2 years old.

6-27

MAINTENANCE INSTRUMENTS FILE. Records related to maintenance of laboratory equipment and instruments.

Retain for the life of the instrument, or when administrative value ends, whichever is sooner.

SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 7 - PHARMACY
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY
7-1

IHS 17-2 - PRESCRIPTION BLANK.  Completed prescription forms are to be kept by the Pharmacist.  Non-Pharmacists cannot fill prescriptions from other providers.

 

Destroy when 3 years old.

7-2

HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) 91 - PHARMACY QUARTERLY & CUMULATIVE REPORTS FILE. This report is forwarded to Area Office on a quarterly basis.  It provides a synopsis of quarterly Pharmacy activities.

Destroy when 3 years old.

7-3

IHS 168 - PHARMACY OPERATIONS: DAILY RECORD & QUARTERLY REPORT.  Pharmacy work load data for statistical reporting purposes.

Destroy when 3 years old.

7-4

HRSA 173 - AUDIT REPORT FOR NARCOTICS AND OTHER CONTROLLED SUBSTANCES FILE.  Certifies when narcotics were inventoried against perpetual records, and describes any discrepancies noted by auditor.

Destroy when 3 years old.

7-5

IHS 174 - MONTHLY REPORT FOR NARCOTICS AND OTHER CONTROLLED SUBSTANCES (PHARMACY) FILES. Certifies when narcotics were inventoried against perpetual records, and describes any discrepancies.

Destroy when 3 years old.

7-6

HRSA 176 - PERPETUAL INVENTORY OF NARCOTICS AND OTHER CONTROLLED SUBSTANCES (PHARMACY) FILES.  Tracks receipts and disposition of controlled substances/alcohol to and from Pharmacy inventory.

Destroy when 3 years old.

7-7

IHS 177 - REQUEST FOR NON-FORMULARY MEDICATION FILES.  Request to the Pharmacy and Therapeutics Committee from a provider to add a drug to the formulary.

Destroy when 3 years old.

7-8

HRSA 191 - CONSOLIDATED EIGHT HOUR CONTROLLED SUBSTANCES AUDIT FILES. Verifies that the narcotic count was done, and counts are correct, counts are done by two or more Nurses.

Destroy when 3 years old.

7-9

IHS 219-1 - INVENTORY AND DISPOSITION RECORD:  NURSING UNIT NARCOTICS FILES. Tracks receipts and disposition of narcotics on Nursing Unit.  Receipts are signed by receiving Nurse and Pharmacist.

Destroy when 3 years old.

7-10

HRSA 245 - TRANSFER OF CUSTODY OF CONTROLLED SUBSTANCES AND SPIRITUOUS LIQUORS FILES.  Transfers custody of controlled substances and alcohol to the new Chief Pharmacist before the old Chief leaves.

Destroy when 3 years old.

7-11

HRSA 247 – PHARMACEUTICAL

FORMULATION CONTROL RECORD FILES. Documents compounded items.  Lists control number, person compounding the substance, person checking substance, and date.

Destroy when 3 years old.

7-12

IHS 248 - PHARMACY REQUISITION FILES.  Used by Nursing Units to order drugs from the Pharmacy.

Destroy after workload is recorded.

7-13

IHS 258 - PURCHASE REQUEST PHARMACY FILES.  Informational copies of purchase requests received from Supply Service on drugs requested directly from Contractors.

Destroy when 3 years old.

7-14

IHS 301 - CONTRACT PRESCRIPTION BLANKS FILE.  Completed prescription forms are to be kept by the Pharmacist. Non-Pharmacists cannot fill prescriptions from other providers.

Destroy when 3 years old.

7-15

HRSA 331 - PHARMACEUTICAL BULK COMPOUNDING WORKSHEET FILES.  Documents composition of compounded items, calculations, lot numbers, expiration, and manufacturer of each ingredient.

Destroy when 3 years old.

7-16

IHS 335 - PHARMACY CHRONOLOGICAL CONTROL LOG FILES.  Documents prepackaged items. Lists control number, date, item, quantity prepacked, manufacturer, lot, and expiration date.

Destroy when 3 years old.

7-17

IHS 413 - OFF SCHEDULE STOREROOM ISSUE REPORT FILES.  Used by facilities to order drugs/supplies from the Area Supply Depot between regular order times.

Destroy when 3 years old.

7-18

HEALTH AND HUMAN SERVICES (HHS) 46 STOCK RECORD CARD FILES.  Used to track order quantities, prices, and order dates of drugs purchased directly from the manufacturer.

Destroy when 3 years old.

7-19

FOOD AND DRUG ADMINISTRATION (FDA) 1571 - INVESTIGATIONAL NEW DRUG APPLICATION (IND) FILES.  Used to file an investigational drug protocol, change an existing protocol, add or change the investigator, or file an IND report.

Cut of at close of fiscal year.  Transfer to the FRC when 5 years old.  Destroy when 10 years old.

7-20

FDA 1572 - STATEMENT OF INVESTIGATOR FILES.  This form is used to collect data on all investigators in a clinical study.  The form is forwarded to the study sponsor, not the FDA.

After file is closed retain for 6 years.  Transfer to the FRC when 6 years old. Destroy when 10 years old.

7-21

FDA 1639 - ADVERSE REACTION REPORT (DRUGS AND BIOLOGICS) FILES.  Used to report drug reactions to the FDA.

Destroy when 3 years old.

7-22

FDA 2519F - MEDICAL DEVICE & LABORATORY PRODUCT PROBLEM REPORTING PROGRAM FILES.  Used to report medical device or lab products to the U.S. Pharmacopoeia National Medical Device Problem Reporting Program.

Destroy when 3 years old.

7-23

FDA 3318 - DRUG QUALITY REPORTING SYSTEM (DQRS) FILES.  Used to report drug product problems to the FDA.

Destroy when 3 years old.

7-24

DRUG ENFORCEMENT AGENCY (DEA) 41 - REGISTRANTS INVENTORY OF DRUGS SURRENDERED FILES. Used to document any controlled substances sent to the DEA for surrender or destruction.

Destroy when 3 years old.

7-25

DEA 106 - NOTIFICATION OF THEFT OR LOSS OF CONTROLLED SUBSTANCES FILE.  Reports drug loss or theft to DEA, IHS, and State Board of Pharmacy.

Destroy when 3 years old.

7-26

DEA 222 - CONTROLLED SUBSTANCES ORDER FORM FILES. DEA required order form for all controlled substances.

Destroy when 3 years old.

7-27

DEA 224 - APPLICATION FOR REGISTRATION AND DEA 224-A, RE-REGISTRATION APPLICATION.  Provider and institutional registration required by the Controlled Substances Act.

Destroy when 3 years old.

7-28

EVALUATION RESEARCH CORPORATION (ERC) BIOSERVICES CORPORATION - VACCINE ADVERSE EVENT REPORTING SYSTEM (VAERS-1) FILES. Used to report vaccine adverse events and reactions to the ERC BioServices Corporation. Information goes to the Centers for Disease Control (CDC) and FDA.

Destroy when 3 years old.

7-29

GENERAL SERVICES ADMINISTRATION (GSA) - FEDERAL SUPPLY SCHEDULE FILES. Contains copies of drug contracts with each company, prices, terms, etc. This is an informational copy of the original contract.

Destroy 3 months after contract expiration.

7-30

DEA - CONTROLLED SUBSTANCES BIENNIAL INVENTORY LIST FILES. DEA required biennial inventory of all controlled substances in the facility as of inventory date.

Destroy when 3 years old.

7-31

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS (JCAHO) - MEDICATION AREA INSPECTION RECORDS FILE. This form verifies that all Nursing Units are checked for outdated drugs, proper storage of drugs, etc., monthly.

Destroy when 3 years old.

7-32

DEA - SCHEDULE II ORDER FILES. Copies of all controlled substance orders must be kept for DEA/Area inspection.

Destroy when 3 years old.

7-33

DEA - CONTROLLED SUBSTANCES PRESCRIPTION FILES. Prescription file for all schedule II, and III-V prescriptions must be readily retrievable for DEA/Area inspection.

Destroy when 3 years old.

7-34

DEA - CONTROLLED SUBSTANCES AND ALCOHOL CERTIFICATE FILES. This file contains completed HRSA 191 and IHS 219-1 forms filed in a readily retrievable fashion for DEA/Area inspection.

Destroy when 3 years old

7-35

DEA - PHARMACY PERPETUAL INVENTORY OF CONTROLLED SUBSTANCES AND ALCOHOL FILES. Contains completed IHS 174 and HRSA 176 forms in a readily retrievable fashion for DEA/Area inspection.

Destroy when 3 years old

7-36

PHARMACY REQUISITION FILES. Includes all requisitions received by the Pharmacy from other Departments.

Destroy after workload is recorded.

7-37

FDA - INEFFECTIVE DRUG LIST - DRUG EFFICACY STUDY IMPLEMENTATION (DESI LIST) FILES. Describes drugs that are deemed less than effective by the FDA. Federal funds cannot be expended on less than effective drugs.

Destroy after update is received.

7-38

DRUG INFORMATION FILES. Files of formal drug information searches conducted by the Pharmacy.

Destroy after update is generated.

7-39

IHS - PHARMACY MODULE MANUALS FILE. Technical manuals for the Resource and Patient Management System (RPMS) Pharmacy Module.

Destroy after update is received.

7-40

PHARMACY PROFILE FILES. Inpatient profiles are maintained by the Pharmacist. The outpatient record functions as the Outpatient Pharmacy Profile.

Destroy after update is generated.

7-41

PURCHASE ORDER FILES. Includes all purchase orders (PO's) for drugs generated by the manufacturer/distributor.  PO's are part of the drug audit trail.

Destroy when 3 years old.

7-42

INPATIENT ORDER COPIES FILE. No Carbon Required (NCR) copies of physician's orders.  Includes all other order facsimiles.

Destroy after order is checked and work load is recorded.

7-43

INVESTIGATIONAL DRUGS FILE.  Includes all records pertaining to the purchase, handling, dispensing, administration, and disposal of investigational drugs.

Cut off on completion of study. Destroy 10 years later.


SCHEDULE 3.  PROFESSIONAL SERVICES

SECTION 8 - SOCIAL WORK SERVICES
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

8-1

PATIENT INDEX FILES. Social work service data cards or other Automated Data Processing (ADP) generated listings of individuals, including basic identifying data.

Transfer active cards to inactive section after case is closed.  Destroy inactive cards after 6 years of social work inactivity.

NOTE: When a case is reopened before the end of 6 years, the information on the old card(s) will be brought forward to the new card(s) and the old card(s) destroyed immediately.

8-2

SOCIAL WORK CLINICAL WORKING FILES. Copies of social work reports, working papers, treatment, progress notes and related material. In some cases, these are kept in the Medical Records computer systems.

Destroy after purpose has been served. NOTE: This record series will not be maintained beyond 6 years.

8-3

SOCIAL WORKER INDEX FILES. Copies of social work service data cards used as an index to the social work cases including ADP generated listings and/or patient data code sheets.

Destroy after case is closed and after preparation of necessary reports and summaries.

8-4

COMMUNITY PLACEMENT FACILITIES FILES. Application for participation in Community Placement Program.  Correspondence to and from IHS and Community placement facilities and related materials.

Destroy approved applications 1 year after home withdraws from program.  Destroy disapproved applications after 5 years.

8-5

GENERAL RESOURCE FILES.  Records of information of health, welfare, legal, and financial resources for patients and their dependents.  Brochures, pamphlets, etc., and related material.

Destroy when obsolete or rescinded.

8-6

HOME RESOURCE FILES.  Cards indicating the name and address of the facility, type, status as to certification or licensing, method and frequency of evaluation, source of data, names of IHS patients entering the facility, dates and monthly charges.

Destroy 1 year after home withdraws from program.


SCHEDULE 3.  PROFESSIONAL SERVICES

SECTION 9 - EYE CARE PROGRAM
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

9-1

PATIENT NOTIFICATION. Call for appointment - Computer-generated form letters.

Retain file copy in patient's Medical Records File.  Destroy in accordance with Schedule 3, Item 3-1.

9-2

GENERAL EXAMINATION FORM. (OPTOMETRY PCC ENCOUNTER RECORD).

Retain file copy in patient's Medical Records File.  Destroy in accordance with Schedule 3, Item 3-1.

9-3

FLUORESCEIN ANGIOGRAM FILES (BY OPTOMETRY). Original films.

Retain file copy in patient's Medical Records File.  Destroy in accordance with Schedule 3, Item 3-1.

9-4

VISION SCREENING SUMMARY FORM.

Destroy after scheduled examination.

9-5

IHS 1099 REFERRAL FORM. Form requests for consultation referral.

Retain a copy of the referral in the patient's Medical Records File.  Destroy copy of the referral when the consultant returns the original referral.  Destroy in accordance with Schedule 3, Item 3-1.

9-6

CONSULTATION LETTERS. Report from consultant to Optometry.

Retain file copy in patient's Medical Records File.  Destroy in accordance with Schedule 3, Item 3-1.

9-7

PATIENT SPECTACLE ORDERS (Rx). Dispensary copy.

Retain in dispensary until prescription is delivered.  Maintain all orders specific to spectacle vendors for 2 years, then destroy.

NOTE:  Retain a copy in the patient's Medical Records File at the time of dispensing.  Destroy in accordance with Schedule 3, Item 3-1.

9-8

OUTPATIENT FEE SLIPS (SPECTACLES AND CONTACT LENSES).

Cut off fee slip file annually.  Destroy when 2 years old.


SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 10 – PREVENTIVE HEALTH
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY
 

RESERVED

 

SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 11 - ENVIRONMENTAL HEALTH
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

11-1

ENVIRONMENTAL HEALTH REPORTING SYSTEM FILES. Records of activities conducted by the Department of Environmental Health (DEH) staff in the Environmental Health Services Branch (EHSB) and the Sanitation Facilities Construction Branch (SFCB) programs.

Destroy when  __  years old.

NCI-90-77-3/15D(7)

11-2

RADON FILES. A baseline assessment of indoor radon levels in all IHS occupied buildings.

Cut off files in 3 year blocks.  Transfer to the FRC when 10 years old.  Destroy when oldest records are 20 years old.

11-3

COMPREHENSIVE SURVEYS OF BUREAU OF INDIAN AFFAIRS FACILITIES FILES. Reports of environmental conditions and recommendations for corrections of these facilities.

PERMANENT.  Cut off files every 3 years. Transfer to the FRC when administrative value ends, or when 10 years old, whichever is sooner.  Destroy when 20 years old.

11-4

U.S. PHS PERSONNEL MONITORING PROGRAM.  Radiation Dosimetry Records for IHS occupationally exposed persons.

Cut off files in 3 year blocks.  Transfer to the FRC when administrative value ends, or when 10 years old, whichever is sooner.  Destroy when 20 years old.

11-5

ETHYLENE OXIDE, FORMALDEHYDE AND ASBESTOS PERSONNEL EXPOSURE RECORDS. Records of individuals who may be occupationally exposed to these hazardous materials.

Cut off files in 3 year blocks.  Transfer to the FRC when administrative value ends, or when 10 years old, whichever is sooner.  Destroy when most recent record is 30 years old.

11-6

PATIENT ENDURANCE SKIN EXPOSURE (ESE) FILES. Reports of radiation exposure measurements using selected radiographic techniques and nonanatomical phantoms.

Maintain at Area Offices and Headquarters. Cut off annually.  Destroy when 5 years old.

11-7

CONSTRUCTION AND FACILITIES PLANNING PROJECTS FILE. Case files containing copies of bids, project proposals and summaries, specifications and drawings, contracts, reports and correspondence in connection with P.L. 86-121.

Cut off on completion of project.  Transfer to the FRC when 2 years old.  Destroy when 6 years old.

11-8

DRAWINGS AND SPECIFICATIONS FILE. Drawings and specifications pertaining to the construction of Indian hospitals and other facilities for the beneficiary populations.

Destroy when superseded, obsolete, or when building is sold or demolished.  Copies should be maintained at both the Area and Field offices.

11-9

ENVIRONMENTAL HEALTH PROGRAMS CONSTRUCTION PROJECT RECORDS.  Legal documents pertaining to the administration of the program, periodic and special reports, final reports (narrative booklets) describing projects, problems, summary of costs, tribal participation on task force studies and surveys relating to health effects of economic and industrialization on Indian reservations.  Official correspondence in connection with P.L. 86-121, housing, health centers, hospitals, water and sewage.

PERMANENT. Cut off files every 3 years. Transfer to the FRC when administrative value ends, or when 10 years old, whichever is sooner.  Transfer to the National Archives when 20 years old.

11-10

SANITATION RESEARCH AND SPECIAL STUDY FILES.  Reports, studies, surveys and recommendations relating to housing, water supply, sewage treatment and disposal, insulation materials, home plumbing, periodic and special reports on sanitary conditions at field stations, facilities, and operation of medical installations.

Cut of on completion of project.  Transfer to the FRC when administrative value ends or when 3 years old, whichever is sooner. Destroy when 6 years old.

11-11

SANITATION FACILITIES CONSTRUCTION (SFC) INDIVIDUAL APPLICANT FILES. This record series contains all professional and administrative material necessary to document individual sanitation facilities provided by the IHS and/or requested by the individual. It contains documentation regarding the individual’s eligibility for sanitation facilities under P.L. 86-121. It contains, in written and graphic form, documents released to sanitation services provided or requested.

  1. Sanitation services provided. All related correspondence and documents.
  2. Sanitation services not provided (e.g., ineligible).

  1. Transfer to the FRC when administrative value ends, or after 10 years of inactivity, whichever is sooner. Destroy 20 years after retirement to the FRC.

  2. Transfer to the FRC when administrative value ends, or after 10 years of inactivity, whichever is sooner. Destroy 20 years after retirement to the FRC.

SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 12 – HEALTH EDUCATIONSECTION 3 - MEDICAL RECORDS
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

12-1

HEALTH PROMOTION/DISEASE PREVENTION FILES.  Records containing project proposals of local (Service Unit) and Area initiatives for physical fitness programs, cessation of smoking, alcohol and substance abuse prevention, diabetes, teen pregnancy, and other health promotion efforts.

Cut off at the close of the fiscal year.  Destroy when 3 years old.

12-2

HEALTH EDUCATION RESOURCE MANAGEMENT SYSTEM WORK LOAD DATA FILES.  A reporting system containing information on the efficiency and effectiveness of Health Education Services as reported by field Health Education Staff. Aggregate data is available on an annual basis.

Cut off at the close of the fiscal year.  Destroy when 2 years old.

NCI-90-77-3/15D(6)

12-3

SCHOOL HEALTH PROJECT FILES. Project is funded by the Centers for Disease Control (CDC). Files contain information on the development, implementation and evaluation of materials and reports related to comprehensive school health education.  Progress, trip and funding reports are maintained

Cut off when project is completed.  Transfer to the FRC when 2 years old.  Destroy when 6 years old.

12-4

SLIDE SHOW PROGRAM FILES. Boxed slide programs contain historical and clinical information on IHS and IHS Health Education Program.  Accompanying scripts are available with some of the programs.

a. Record set. 2 copies of each slide program set, plus 2 copies of the accompanying script.

b. All other copies.

a. PERMANENT. Cut off at the close of fiscal year.  Transfer to the FRC when 2 years old. Transfer to the National Archives when 10 years old.

b. Destroy when no longer needed.


SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 13 – MATERNAL AND CHILD HEALTH
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

13-1

AMERICAN ACADEMY OF PEDIATRICS FILE. Meetings, site visit reports, responses, and correspondence.

Destroy when 3 years old.

13-2

AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS.  Meetings, site visit reports, responses, and correspondence.

Destroy when 3 years old.

13-3

IHS SENIOR CLINICIANS, MATERNAL AND CHILD HEALTH (MCH) RELATED FILES.  Reports on Obstetrics/Gynecology, Pediatrics, Midwifery, Pap Smear Utilization Reports and Provera Surveillance.

Destroy when 3 years old.

13-4

FAMILY PLANNING FILES. Consists of sterilization reports.

Close files every 3 years.  File inactive records in the patient's Medical Records File.

13-5

HYSTERECTOMY REPORTS FILE.

Close files every 3 years.  File inactive records in the patient's Medical Records File.

13-6

ABORTION REPORTS FILE.

Close files every 3 years.  File inactive records in the patient's Medical Records File.

13-7

PREGNANCY AND DELIVERY (BIRTHS) FILE. Consists of reports on prenatal care, perinatal care, postpartum care, and high risk obstetric/neonatal care.

Close files every 3 years.  File inactive records in the patient's Medical Records File.

13-8

ADOLESCENT HEALTH CARE FILES. Reports on Sudden Infant Death Syndrome, Fetal Alcohol Syndrome, immunizations, child abuse and neglect, data base project, and teen pregnancy.

Cut off annually.  Transfer to the FRC when 3 years old or when administrative value ends, whichever is sooner.  Destroy when 7 years old.


SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 14 – MENTAL HEALTH PROGRAMS
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

14-1

CLINICAL PSYCHOLOGY FOLDER FILES. Notes, psychological evaluations, recording sheets, psychological test material, and related material.

Warning:  Records such as caregiver’s notes of sessions, patient history, and other information covered by doctor-patient confidentiality should not remain in 14-1 through

14-3 after the case is closed.  Use 14-4.  Copies of physical, radiological, and neurological examinations, and results of laboratory tests should be forwarded to the PMR.

Cut off on close of case.  Transfer to FRC when 3 years old, or when administrative value ends.  Destroy when 50 years old.

14-2

MENTAL HEALTH RECORDS FILE. Detailed working notes of the clinical therapist’s records of therapy sessions, psychological test books, protocols and other psychological data, trial visit notes, psychological evaluations, treatment and progress notes.  Additional assessment procedures (physical examinations, laboratory tests, radiological examinations, school records, legal status records), hospital reports of examinations, release of information documents, correspondence, and copies of initial periodic, and closing reports.

Cut off on close of case.  Transfer to FRC when 3 years old, or when administrative value ends.  Destroy when 50 years old.

14-3

PSYCHOLOGY TEST DATA AND WORK SHEETS FILE. Psychological test material, case notes, worksheets, evidence of appropriate consultation, and related material.  A report should be included which interprets all data collected, including test scores.

Cut off on close of case.  Transfer to FRC when 3 years old, or when administrative value ends.  Destroy when 50 years old.

14-4

MATERIALS SUBJECT TO DOCTOR-PATIENT CONFIDENTIALITY. Records such as case notes of therapy sessions containing information about patient history which the therapist would not normally divulge to a successor.

Cut off on close of case.  Destroy when 50 years old.


SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 15 – PHYSICAL THERAPY
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

15-1

REHABILITATION MEDICINE PATIENT PROGRESS NOTES FILE.  Copies of various clinical records and related documents (i.e., medical tests and measurements received back from notes on field visits or home care) used to record treatment and services provided to patients are combined in this file upon completion of treatment.

File in patient's Medical Records File.  Destroy in accordance with Schedule 3, Item 3-1.

15-2

PROGRESS NOTES FILE. Includes notes on outpatient and inpatient health care, medical tests and measurements received back from notes on field visits or for home care.

File in patient's Medical Records File. Destroy in accordance with Schedule 3, Item 3-1.

15-3

PATIENT CARE REFERRAL FILES. Consists of all outpatient referrals from IHS facilities, all non-IHS referrals, i.e., contract care or third party resources.

File in patient's Medical Records File. Destroy in accordance with Schedule 3, Item 3-1.

15-4

FORMS FOR RECORDING FILES. Consists of all outpatient referrals from IHS facilities, all non-IHS referrals, i.e., contract care or third party resources.

Destroy when 1 year old.

15-5

DUTY STATUS FILES. Statement of Fitness for Duty written by health care providers to designate "Fit for Duty," "Not Fit for Duty,” or "Fit for Light Duty."

Destroy when 1 year old.

15-6

PHOTO PERMIT FILES. Form designated for photo documentation of patient problems when the patient can be identified.

File in patient's Medical Records File. Destroy in accordance with Schedule 3, Item 3-1.

15-7

DAILY AND SPECIALTY CLINIC ATTENDANCE RECORDS FILE.  Patients' attendance records indicating patients' names, numbers, diagnosis, treatment and record of attendance.

Destroy when 2 years old.

15-8

EQUIPMENT FILES CHARGE OUT/RETURN FILES.  Record of equipment loaned to patients for temporary or permanent use in home healthcare.

Destroy following equipment return.


SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 16 – COMMUNITY HEALTH REPRESENTATIVE PROGRAM
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

16-1

COMMUNITY HEALTH REPRESENTATIVES INFORMATION SYSTEM (CHRIS II) FILES. A reporting system collecting data on the health area, service, setting, number served, time spent, age, sex and referrals as reported by Community Health Representatives (CHRs); for effective management, training and allocation of appropriated resources.  Data are aggregated and available on an annual basis.

a. Data entry/processing contract for CHRIS II, includes vouchers, edit reports, etc.

b. CHR - Professional Specialty Group (PSG) – Needs Productivity Model (NPM) meetings and work session notes.

PERMANENT. Maintain 4 years or after historical biography has been completed. Transfer to the FRC for 3 years then offer to the NARA.

16-2

TRAINING FILES. (Maintained at Rapid City, SD, Black Hills Training Center).

a. Area training plans, proposals and reports on CHR advanced, refresher and specialty courses, including number trained, cost, subject matter, Continuing Education Units (CEUs), college credits, etc.  This is a basic 3-week course.

b. Annual reports from the 5 Regional CHR Training Centers include number enrolled, number successful in completing course, and number receiving 5 college credit hours in Allied Health or Community Health.

a. Cut off annually.  Destroy when 10 years old.

b. Cut off annually.  Destroy when 5 years old.

16-3

REPORTS TO THE FIELD FILES.  The CHR Program Update (sent quarterly) contains information of interest to the CHR program contractors, Area offices, Service Units, as well as CHRs.

a. Record copy (HQ).

b. All other copies.

a. PERMANENT. Cut off every 5 years. Transfer to the FRC when 2 years old. Transfer to the National Archives when 20 years old.

b. Destroy when no longer needed.

16-4

EVALUATION/RESOURCE ALLOCATION METHODOLOGY FILES.  Documents, i.e, purchase orders, contracts related to development of the evaluation as well as recommendations, reports, participants, etc.

Cut off annually. Destroy when 6 years, 3 months old.


SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 17 - EMERGENCY MEDICAL SERVICES
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

17-1

EMERGENCY MEDICAL SERVICES FILES.  The purpose of this program is to provide assistance and encouragement for Emergency Medical Services Systems throughout the country, thereby improving the quality of patient care and reducing morbidity and mortality.

These records consist of, or relate to, such matters as feasibility and planning, establishment of the systems, expansion and improvements, research, training, reviews, needs and cost estimates, applications for expansions and inventories of facilities.

Transfer to the FRC after final payment. Destroy when 4 years old.


SCHEDULE 3. PROFESSIONAL SERVICES
SECTION 18 – ALCOHOLISM/SUBSTANCE ABUSE PROGRAMS
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

18-1

ALCOHOLISM TREATMENT GUIDANCE SYSTEM (ATGS):  A Data System developed by IHS to guide and monitor the provision of services to clients/patients receiving treatment from IHS Contract and Direct Care Programs.  This system also provides program accountability by documenting client services and staff activity.

ATGS A. May be used for any short-term services (less than 30 days); the form requirement in that case must be opened and closed within the same month.  If used, it replaces ATGS 1, 7, and 9.

Destroy 6 years after last episode of care.

18-2

CLIENT CASE FILE: ATGS 1 - 10 OR EQUIVALENT.

Destroy 6 years after last episode of care.

18-3

ATGS DATA SYSTEM.

a. INPUTS. Derived from the client case file.

b. DATA AND SYSTEM DOCUMENTATION (at the HQ level).

c. DATA AND SYSTEM DOCUMENTATION (below HQ level).

a. Destroy after data entry, unless data entry is directly from Client Case file.

b. PERMANENT. Cut off data at 5 year intervals. Transfer data and related documentation to National Archives immediately.

c. Destroy when no longer needed.

18-4

DEMOGRAPHIC REPORTS FILE.  Mailed out as requested.

Destroy when 1 year old.

18-5

SERVICE CODE REPORTS FILE.  Mailed out on a monthly basis.

Destroy when 1 year old.

18-6

*ATGS-A REPORTS FILE.  Mailed out on a monthly basis.

Destroy when 1 year old.

18-7

*SERVICES/DISCHARGE REPORTS FILE. Mailed out on a monthly basis.

Destroy when 1 year old.

18-8

*QUARTERLY REPORTS FILE.  Mailed out on a quarterly basis.

Destroy when 1 year old.

18-9

INITIAL CONTACT FOLLOW-UP LIST.  Mailed out on a monthly basis.

Destroy when 1 year old.

18-10

ANNUAL SUMMARY.  Mailed out annually.

Destroy when 1 year old.

SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 19 – URBAN INDIAN HEALTH PROGRAM
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

19-1

RESERVED

 

SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 20 – AUDIOLOGY AND SPEECH PATHOLOGY
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

20-1

HEARING AID LOANER FILES.  Present hearing aid stock replacement records, and loaner aid records listed by manufacturer and model.

Destroy when 1 year old.

Destroy when 1 year old.

Destroy after equipment is returned.

Destroy when 1 year old.

Destroy after the new updated inventory file is in place.

Destroy after transfer to the Audiology Accumulative Record.

Cut off on close of case and place in an inactive file.  Cut off inactive file annually. Transfer to the FRC when 3 years old or when administrative value ends, whichever is sooner.  Destroy when 9 years old.

Destroy when 2 years old.

20-2

HEARING AID BATTERY RECORDS FILE.  Dates of request and receipt of batteries by battery type.

Destroy when 1 year old.

20-3

EQUIPMENT CHARGE-OUT FILES.  Records of equipment charged out to patients by dates.  Card file is maintained by type of equipment.

Destroy after equipment is returned.

20-4

CLINICAL APPOINTMENT SCHEDULES.  Daily record of appointments of both audiology and speech pathology patients.

Destroy when 1 year old.

20-5

HEARING AID INVENTORY FILES. Complete records of semi-annual hearing aid inventories.

Destroy after the new updated inventory file is in place.

20-6

CLINICAL AUDIOLOGY AND SPEECH PATHOLOGY PROGRESS NOTES FILE.  Case histories, evaluations, recording sheets, reports, treatment and progress notes and related material.

Destroy after transfer to the Audiology Accumulative Record.

20-7

AUDIOLOGY ACCUMULATIVE RECORDS FILE. Evaluation Results for rating examinations.

Cut off on close of case and place in an inactive file.  Cut off inactive file annually. Transfer to the FRC when 3 years old or when administrative value ends, whichever is sooner.  Destroy when 9 years old.

20-8

COMMERCIAL SOURCE FOLDER FILES.  Copies of invoices filed chronologically by date.

Destroy when 2 years old.

20-9

HEARING AID RECORDS FILE (PROSTHETICS DISTRIBUTION CENTER. Hearing aid repair and battery records or equivalent.

a. Active cards.

b. Inactive cards.

c. Cards whose status cannot be determined.

a. Transfer completed cards to an inactive file upon beginning of a new card.  Cut off inactive file annually.  Destroy when 6 years old.

b. Immediately destroy the following completed cards:

- Of deceased beneficiaries.

- After termination of eligibility.

- When items are no longer medically indicated.

c. Destroy any card after 3 continuous years of inactivity.

20-10

HEARING AID FILES. Requests for hearing aids and hearing aid batteries.

Destroy when 1 year old.


SCHEDULE 3. PROFESSIONAL SERVICES

SECTION 21 - NUCLEAR MEDICINEMEDICAL RECORDS
ITEM NO. TITLE AND DESCRIPTION OF RECORD DISPOSITION AUTHORITY

21-1

NUCLEAR MEDICINE LICENSE FILES.  Licenses issued by the Nuclear Regulatory Commission which permit approved IHS hospitals to use radioactive material for diagnostic, therapy, teaching, and research purposes.  Amendments of licenses, notices of violation, orders to show cause, and related material.

Cut off upon cancellation or expiration of license.  Destroy when 5 years old.

21-2

INSPECTIONS, TESTS, AND SURVEYS FILE. Records of inspections, tests, and surveys of radiographic exposure devices, survey instruments and storage containers, and related material.

Destroy after inspection by the Nuclear Regulatory Commission.

21-3

RADIATION MONITORING FILES. Monitoring equipment records measuring the dosage of radiation received, and related material.

Destroy when 75 years old.

21-4

NUCLEAR MEDICINE REPORTS FILE. Reports of exposure to radioactive material, reports of loss or theft of radioactive material, and any other report required by the Nuclear Regulatory Commission.  Includes reports recording the amount of radiation used on IHS patients or personnel.

Destroy when 10 years old.

NOTE: Reports recording the amount of radiation used on IHS patients or personnel should be incorporated into the PMR or Employee Medical Folder as appropriate.

21-5

RADIOACTIVE MATERIAL INVENTORY AND CONTROL FILES. Inventory and control records used to account for all radioactive material on hand by individual type, date received, method of distribution and disposition.

Destroy after inspection by the Nuclear Regulatory Commission.

21-6

NUCLEAR SCAN FILES (GENERAL). Nuclear scans and copies of interpretations maintained for treatment purposes and not being used for purposes of teaching, active research or cooperative studies.

Destroy 5 years after date of latest scan and after report has been filed in the patient's Medical Records File.

21-7

NUCLEAR SCAN ALPHABETICAL INDEX FILES.  An alphabetical cross index to nuclear scans which are filed numerically by Social Security numbers, annotated to reflect removal from Nuclear Scan Files (General) and placed in teaching or research and cooperative studies files.

Destroy when related nuclear scans are destroyed.

21-8

NUCLEAR SCAN PATHOLOGICAL INDEX FILES. Card indexing special interest scans, normal and abnormal, for medical reference purposes.

Destroy when no longer of medical reference value or when card is replaced.

21-9

NUCLEAR SCAN (FILES - TEACHING). Nuclear scans and copies of interpretations selected for teaching and educational purposes.

Return to Nuclear Scan File (General) for appropriate disposition when teaching purposes have been served.  Destroy immediately if file is more than 5 years from the date of latest scan in folder.

21-10

PATIENT THERAPY FILES. Records of course of treatment, therapy, summaries, progress notes, therapeutic doses of radio-pharmaceuticals received, and technical factors applied.

Destroy 10 years after last episode of treatment or follow-up care and after report has been filed in the patient's Medical Records File.

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