Medical Records:Making and Retaining Them

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Medical Protection Society. Making and keeping medical records. MPS Casebook. Jul 2000:6-8

          http://www.mps.org.uk

Ministry of Health, Singapore.  Retention Periods for Medical Records – Meeting Legal Requirements.

         Circulars No. 1/96 and 3/96.

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        1999: 14

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ANNEX 1 - REVISED RETENTION PERIODS FOR MEDICAL RECORDS

(1 FEBRUARY 1996)

./1      ]

/2      ]        Please see explanatory notes attached

/3      ]

-  Records to be retained for 3 years at the clinic and a further 2 years at another location

/RE312(RETENTN.DOC)  [source: MOH circular 1/96]

NOTES:

1.      Retention Period

                Retention period refers to the period following the date of last discharge from hospital or last attendance at the Outpatient Clinic.

2.      Primary Medical Records

2.1                 Primary Medical Records refer to all the original inpatient and outpatient records generated at the time of admission or outpatient attendance.

2.2                 After the specified period of retention, primary records must be culled by extracting the forms listed in para 3 below, which will be assembled to form the Secondary Medical Records

3.      Secondary Medical Records

         Secondary Medical Records include the following documents of patients:

·     Inpatient / Outpatient Discharge Summary

·     Operation Report Form

·     Consent for Operation Form

·     X-ray Report Form

·     Histopathology Investigation and Report Form

·     Maternity Record Form

·     Labour Record Form

·     Neonatal records which are enclosed in the mother’s casenotes

·     Workmen’s Compensation Reports, Insurance, Medical and other Medico-Legal Reports

4.      Microfilmed Records

Original paper secondary medical records of patients which have been microfilmed may be destroyed.  Before destruction of the original documents, hospitals/institutions must first ensure that the microfilmed records are properly kept and that the microfilms are clearly catalogued for easy retrieval.

         Minimum retention period for microfilmed secondary records of patients is 17 years.

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