What are the requirements for maintenance of medical records? How long must a physician maintain a medical record?

Medical Records are an essential part of any medical practice and the delivery of medical care to patients. Medical records provide information necessary for the continuing care and treatment of patients. Accurate record keeping and maintenance can also provide protections for physicians against claims of professional liability and board actions. Missouri law provides a minimum for what medical records must contain.

Pursuant to Missouri Revised Statute 334.097,

“1 Physicians shall maintain an adequate and complete patient record for each patient and may maintain electronic records provided the record-keeping format is capable of being printed for review by the state board of registration for the healing arts. An adequate and complete patient record shall include documentation of the following information:

1. Identification of the patient, including name, birthdate, address and telephone number;
2. The date or dates the patient was seen;
3. The current status of the patient, including the reason for the visit;
4. Observation of pertinent physical findings;
5. Assessment and clinical impression of diagnosis;
6. Plan for care and treatment, or additional consultations or diagnostic testing, if necessary. If treatment includes medication, the physician shall include in the patient record the medication and dosage of any medication prescribed, dispensed or administered;
7. Any informed consent for office procedures.”

Physicians should strive to document as much information as possible to detail the condition that the patient presented, the conversations between physician and patient relative to the patient healthcare, the diagnosis and basis for same, and the treatment plan. Physicians should also note the patient’s acknowledgement of understanding of both the treatment and any risks. A detailed and complete medical record allows the physician to provide the best possible care to the patient. It will also assist other treaters who rely on those records to treat patients. Well documented medical records can also assist in the defense of a medical malpractice claim, therefore physicians should take care to document such records as completely and comprehensively as possible.

So how long should a physician maintain medical records?

Ideally, the records should be maintained throughout the duration of your practice. One never knows if a patient may return to the practice after an extended time, or another treater may require records to assist in the treatment of the patient.

Missouri statutes mandate the minimum amount of time that a medical record shall be kept by a physician.

Missouri Revised Statute 334.097 (2) provides that “Patient records remaining under the care, custody and control of the licensee shall be maintained by the licensee of the board, or the licensee’s designee, for a minimum of seven years from the date of when the last professional service was provided.”

The seven years record retention from the date that the patient is last seen is the absolute minimum amount of time that the state of Missouri requires for medical record retention. However, as these records may also be needed to defend a claim of medical malpractice, the records must be maintained for a sufficient period of time to be available if a claim of medical malpractice is filed by a patient. The statute of limitation in Missouri is two (2) years, three (3) in the case of wrongful death. However, this limitations period can be extended for various defined reasons up to a period of ten years. In the case of a minor, the statute of limitations does not begin to run until the minor turns 18, at which time they will have a minimum of two years to bring a cause of action and more if the statute of limitations is tolled. If the records cannot be maintained indefinitely, physicians should consider maintaining records for a period of ten years from the date the patient is last seen for adult patients, and for a period of ten years from the date that a minor patient come of age.

Physicians should also take care to confirm any requirements for record retention requirements provided in managed care agreements, HMO, medicare plans, or any other contractual obligations.

Given the immense importance of medical records to both patient care and defense of any claims of malpractice, physicians should take care to ensure the records are accurate and complete, and maintained for appropriate amount of time.