Search Results

GS-20: Health Records

Series Number Series Title Description Retention Disposition Citation Approval Date
200885 Accreditation Records This series documents hospital accreditation by a relevant health-accreditation body. This series may include, but is not limited to: accreditation results, plans for improvement, inspection results, consultation records, audits, reports and other documentation as required by the accreditation organization. Retain 5 year(s) after superseded, obsolete, or rescinded Confidential Destruction 9/11/2025
200886 Animal Bite and Quarantine Records This series documents the reporting of animal bites and the quarantine of animals. This series may include, but is not limited to: reports, responses, and quarantine logs. Retain 3 year(s) after end of calendar year Confidential Destruction 9/11/2025
200887 Animal-Head Test Results This series documents the performance of animal-head testing on animals suspected of carrying rabies. This series may include, but is not limited to: animal-head test result. Retain 8 year(s) after end of calendar year Non-confidential Destruction 9/11/2025
200888 Appointment and Scheduling Records This series documents the scheduling and completion of in-house appointments and the scheduling of outside-referral appointments. This series may include, but is not limited to: calendars and logs. Retain 5 year(s) after end of calendar year Confidential Destruction 9/11/2025
200889 Assignment Sheets This series documents staff members on duty in a unit for a particular shift, including physicians and on-call physicians, nurses, and patient care technologists. This series may include, but is not limited to: assignment sheets and physician on-call lists. Retain 10 year(s) after end of calendar year Confidential Destruction 9/11/2025
200890 Autopsy Reports This series documents a decedent's cause and manner of death. This series may include, but is not limited to: autopsy reports. Retain 10 year(s) after end of calendar year Confidential Destruction 9/11/2025
200891 Biological and Medical Waste Disposal Records This series documents the disposal of hazardous medical and biological waste or transfer to certified disposal vendors. This series may include, but is not limited to: logs. Retain 3 year(s) after end of calendar year Non-confidential Destruction 9/11/2025
200892 Cardiac Monitoring Recordings This series documents cardiac monitoring of patients. This series may include, but is not limited to: recordings and activity reports. Retain 5 year(s) after last action Confidential Destruction 9/11/2025
200893 Charge Nurse Reports This series documents charge nurse change-of-shift notes and reports on patients. This series may include, but is not limited to: reports and notes. Retain 5 year(s) after end of calendar year Confidential Destruction 9/11/2025
200894 Complaint Files This series documents the receipt of and response to complaints from both patients and the general public. This series may include, but is not limited to: correspondence. Retain 5 year(s) after last action Confidential Destruction 9/11/2025
200895 Compliance Records This series documents compliance with federal rules, regulations, guidance and advisories pertaining to healthcare programs, including the False Claims Act. This series may include, but is not limited to: complaints and responses, reports, audits, event and other documentation. Retain 10 year(s) after end of calendar year Confidential Destruction 9/11/2025
200896 Criminal Background Checks: Health Services This series documents the criminal background check results of a job applicant in the Health Services industry for the purpose of compliance with accreditation standards within the industry. This series may include, but is not limited to: criminal background investigations, reports, fingerprint cards, and other security records. Retain 5 year(s) after termination Confidential Destruction 9/11/2025
200897 Diagnostic Testing and Imaging Records This series documents the performance and results of diagnostic testing and imaging, such as, but not limited to: electrocardiograms, encephalograms, nerve and pulmonary function testing, cardiac catheterization, and radiology tests including x-rays, computerized tomography (CT) scans, magnetic resonance images (MRI), and ultrasounds. Final report is added to patient medical record. This series may include, but is not limited to: clinic/lab copies of tracings, printouts, images, films, scans, and interpretation reports. Retain 10 year(s) after closed Confidential Destruction 9/11/2025
200898 Equipment Sterilization Records This series documents the in-house sterilization of supplies and equipment and/or the receipt, control and distribution of sterilized supplies and equipment. This series may include, but is not limited to: logs and reports. Retain 3 year(s) after end of calendar year Non-confidential Destruction 9/11/2025
200899 Fetal Death Reports This series documents fetal deaths, including stillbirths and terminations in compliance with the Code of Virginia 32.1-264. This series may include, but is not limited to: reports. Retain 1 year(s) after creation Confidential Destruction 9/11/2025
200900 Fetal Monitoring Recordings This series documents fetal monitoring activities. This series may include, but is not limited to: recordings and activity reports. Retain 10 year(s) after end of calendar year Confidential Destruction 9/11/2025
200901 Health Insurance Portability and Accountability Act (HIPAA) Records This series documents compliance with the Health Insurance Portability and Accountability Act (HIPAA) regulations. This series may include, but is not limited to: correspondence, reports, plans, policies, procedures, complaints, disclosure forms, and training material. Retain 6 year(s) after end of calendar year Confidential Destruction 9/11/2025
200902 Immunization Records: Adult This series documents adults who receive immunizations that are not included as part of a patient medical record. This series may include, but is not limited to: consent forms, encounter forms, service slips and logs. Retain 5 year(s) after event Confidential Destruction 9/11/2025
200903 Immunization Records: Minor This series documents minors who receive immunizations that are not included as part of a patient medical record. This series may include, but is not limited to: consent forms, encounter forms, service slips and logs. Retain 21 year(s) after birth Confidential Destruction 9/11/2025
200904 Incident Reports This series documents patient and non-patient safety incidents but does not include employee safety incidents. This series may include but is not limited to: reports and correspondence. Retain 10 year(s) after event Confidential Destruction 9/11/2025
200905 Laboratory and Medical Equipment Maintenance Records This series documents the maintenance and repair of laboratory and medical equipment and instruments. This series may include, but is not limited to: logs and reports Retain 2 year(s) after equipment, facility, or property sold or no longer in use Non-confidential Destruction 9/11/2025
200906 Laboratory: Cytogenetic and Molecular Diagnostic Records This series documents cytogenetic and molecular testing and analysis. This series may include, but is not limited to: final reports, images of fluorescence in situ hybridization (FISH) studies for non-neoplastic disorders, and test reports for constitutional/genetic conditions. Retain 20 year(s) after end of calendar year Confidential Destruction 9/11/2025
200907 Laboratory: Cytopathology and Other Specialized Reports This series documents the performance of cytopathology and other specialized testing. This series may include, but is not limited to: cytopathology reports, surgical pathology reports, images of fluorescence in situ hybridization (FISH) studies, including cytogenetic and molecular studies for neoplastic disorders, gated dot plots, and histograms. Retain 10 year(s) after end of calendar year Confidential Destruction 9/11/2025
200908 Laboratory: Cytotherapy Contracts and Agreements This series documents the responsibilities of any establishment that performs a manufacturing step or provides reagents for cytotherapy. This series may include, but is not limited to: contracts and agreements. Retain 10 year(s) after expiration Confidential Destruction 9/11/2025
200909 Laboratory: Cytotherapy Records This series documents the cytotherapy process, including the collection, processing, compatibility testing, storage and distribution of cellular therapy product, through the final disposition of the product. This series may include, but is not limited to: test results and interpretations, temperature and other logs, quality control records, personnel training and competency records, donor records, procedures and reports. Retain 10 year(s) after final disposition Confidential Destruction 9/11/2025
200910 Laboratory: General Reports This series documents the performance of specimen and pathology testing. This series may include, but is not limited to: laboratory copy of test results, worksheets, logs, and reports. Retain 2 year(s) after end of calendar year Confidential Destruction 9/11/2025
200911 Laboratory: Quality Assurance and Quality Control Records This series documents quality assurance and quality control testing in the laboratory, which may include the calibration of equipment, and the monitoring of equipment, procedures and protocols for effectiveness. This series may include, but is not limited to: instrument printouts and data, temperature logs, performance specifications, testing results, proof of monitoring, and the identification and documentation of problems and corrective actions taken. Retain 2 year(s) after end of calendar year Non-confidential Destruction 9/11/2025
200912 Laboratory: Requisitions, Worksheets and Logs This series documents specimens received, and tests ordered and performed. This series may include, but is not limited to: worksheets, logs, test-order forms, test counts, requisitions, and authorization. Retain 2 year(s) after end of calendar year Confidential Destruction 9/11/2025
200913 Laboratory: Transfusion Medicine Quality Management Records This series documents quality control measures in transfusion administration, including calibration of equipment, performance checks of equipment and reagents, and periodic checks of sterile technique and temperatures. This series may include, but is not limited to: quality management reviews, proficiency testing reports, irradiation-dose delivery reports, retyping of donor units logs, procedural review records, procedures and discontinued procedures. Retain 10 year(s) after end of calendar year Confidential Destruction 9/11/2025
200914 Laboratory: Transfusion Medicine Records This series documents the administration of transfusions, including the collection, processing, compatibility testing, and storage and distribution of blood and blood products. This series may include, but is not limited to: test results and interpretations, final unit dispositions, donor records, temperature and other logs, transfusion reaction reports and evaluations, panel reaction worksheets, and investigation records. Retain 10 year(s) after end of calendar year Confidential Destruction 9/11/2025
200915 Logs This series documents various activities captured on logs that are not covered elsewhere on this schedule. This series may include, but is not limited to: nursing, clinic, decedent, patient activity/registration, operating and specialty rooms, refrigerator temperature, and other miscellaneous logs. Retain until after no longer administratively useful Confidential Destruction 9/11/2025
200916 Master Patient Index (MPI) This series documents patient information for identification purposes and for assignment of medical record numbers. This series may include, but is not limited to: index. Retain 100 year(s) after last action Confidential Destruction 9/11/2025
200917 Medical Debt: Collected This series documents the collection of medical debts paid to healthcare agencies by their patients. This series may include, but is not limited to, contracts, proof of debt, receipts, and invoices. Retain 3 year(s) after closed Confidential Destruction 9/11/2025
200918 Medical Debt: Uncollected - No Action This series documents unpaid medical debts to a health agency that were not acted upon by the agency within 3 years, rendering the debt uncollectable. This series may include, but is not limited to, contracts, proof of debt, receipts, and invoices. Retain until after closed Confidential Destruction 9/11/2025
200919 Medicare and Medicaid Administration Records This series documents the administration of the Medicare and Medicaid programs and non-medical contacts with patients. This series may include, but is not limited to: correspondence, memoranda, and reports. Retain 10 year(s) after closed Non-confidential Destruction 9/11/2025
200920 Medicare, Medicaid, and Insurance Financial Records This series documents Medicare, Medicaid and insurance company billings, reimbursements, and utilization and authorization records. This series may include, but is not limited to: forms and invoices. Retain 10 year(s) after closed Confidential Destruction 9/11/2025
200921 Nursing Home Pre-Admission Screening Reports: Adults This series documents screenings of adults conducted prior to admission to nursing homes. This series may include, but is not limited to: reports. Retain 10 year(s) after last action Confidential Destruction 9/11/2025
200922 Nursing Home Pre-Admission Screening Reports: Minors This series documents screenings of minors conducted prior to admission to nursing homes. This series may include, but is not limited to: reports. Retain 28 year(s) after birth Confidential Destruction 9/11/2025
200923 Outbreak Containment and Investigation Records This series documents the report of and investigation into disease outbreaks or response to other public health emergencies, and efforts to contain outbreaks of contagious diseases or disease-resistant organisms. This series may include, but is not limited to: outbreak report forms, investigation files, test results, reports, memos, and after action review forms. Retain 75 year(s) after last action Confidential Destruction 9/11/2025
200924 Patient Medical/Dental Records: Adults This series documents the treatment history of adult patients receiving medical services. This series may include, but is not limited to: assessment, consultation and treatment records, immunization records, diagnostic testing and imaging records and reports, lab/pathology results and reports, psychiatric notes, and medication administration records. Retain 10 year(s) after last action Confidential Destruction 9/11/2025
200925 Patient Medical/Dental Records: Minors This series documents the treatment history of minor patients receiving medical services when the last treatment was before the age of 18. This series may include, but is not limited to: assessment, consultation and treatment records, immunization records, diagnostic testing and imaging records and reports, lab/pathology results and reports, psychiatric notes, and medication administration records. Retain 28 year(s) after birth Confidential Destruction 9/11/2025
200926 Patient Transportation Records This series documents the movement of patients between medical facilities or between floors or units within the facility, and any medical attention provided during transport. This series may include, but is not limited to: forms and reports. Retain 5 year(s) after end of calendar year Confidential Destruction 9/11/2025
200927 Permit Review Files This series documents participation in any permit-review process where input is provided, but permit is not issued by the local health department. This series may include, but is not limited to: permit applications, inspections, correspondence and other supporting documentation. Retain 2 year(s) after last action Non-confidential Destruction 9/11/2025
200928 Pharmacy: Distribution, Requisition and Prescription Records This series documents the distribution, requisition, replenishment, compounding, and prescription of drugs and other controlled substances, other pharmacy stock, and medical supplies where these items are reimbursable by federal or state programs, or private insurance companies. This series may include, but is not limited to: requisitions, prescriptions, dispensing and filling records, logs, patient medication profiles, drug recall records, audit and reports. Retain 10 year(s) after end of state fiscal year Confidential Destruction 9/11/2025
200929 Pharmacy: Inventory Control This series documents the inventory control of drugs, controlled and non-controlled substances, over-the-counter medications, medical supplies, patient products, and pharmacy and/or nursing stocks. This series may include, but is not limited to: inventories, logs, reports, repackaging records, and destruction forms. Retain 2 year(s) after end of state fiscal year Confidential Destruction 9/11/2025
200930 Procedure Records: Medical This series documents all procedures, treatment protocols, standing orders, and decision tools established to assist clinical operations. This series may include, but is not limited to: clinical pathways and practice guidelines and protocols with supporting materials. Retain 5 year(s) after superseded, obsolete, or rescinded Confidential Destruction 9/11/2025
200931 Radiation Dose and Dosimetry This series documents monitoring information used to determine radiation dose and exposure of employees and other individuals, and equipment for the duration of the site license. This series may include, but is not limited to: individual monitoring results; doses to individual members of the public; dosimetry records; exposure records; uptake of radiation/internal exposure records; As Low As Reasonably Achievable (ALARA) records; results of surveys to determine dose from external sources; results of air sampling, surveys, and bioassays; results of measurements and calculations used to determine individual intakes and the release of radioactive effluents into the environment; declaration of pregnancy forms; dosimeter applications; determination of prior occupational dose; planned special exposure; medical event reports for radioactive material; procedures for administration requiring a written directive; and dosimetry equipment calibration/comparison/inter-comparison records required for teletherapy, remote afterloader, and gamma stereotactic radiosurgery units. Retain 5 year(s) after termination Confidential Destruction 9/11/2025
200932 Radioactive Material Medical Use Records This series documents the use of radioactive material for medical treatment. This series may include, but is not limited to: safety instructions, written directives, sealed source inventories, treatment unit calibration records, concentration and dosage amount documentation, records of testing and inventorying sealed sources and brachytherapy sources, receipt and transfer records, treatment records, byproduct documentation, patient dosage, dose calibrator quality control records, implant installation and removal records, patient release instructions, therapy nursing instructions, therapy equipment calibration and spot-checks, and mobile medical services. Retain 3 year(s) after end of calendar year Confidential Destruction 9/11/2025
200934 Radioactive Material: Calibrations This series documents calibrations of radiation survey instruments, brachytherapy sources, instruments used to measure activity of unsealed radioactive material, and meters. This series may include, but is not limited to: results of calibrations. Retain 3 year(s) after event Confidential Destruction 9/11/2025
200933 Radioactive Material: Category 1 and 2 Irradiator Users This series documents applications for access to Category 1 and 2 sources (irradiators) and operation of other irradiators. This series may include, but is not limited to: applications and results of FBI background checks and fingerprinting. Retain 3 year(s) after event Confidential Destruction 9/11/2025
200935 Radioactive Material: Facility Usage This series documents the designation of facilities that use radioactive material, for the duration of the site license. This series may include, but is not limited to: room use commissioning records, radioactive lab and equipment decommissioning records, and reports of spills, incidents, and accidents involving radioactive material for which continued contamination exists after remediation efforts. Retain 3 year(s) after event Confidential Destruction 9/11/2025
200936 Radioactive Material: Surveys This series documents surveys of areas where radioactive material is used. This series may include, but is not limited to: survey results and recommendations; radioactive material swipe survey reports; records of spill, incidents, and accidents involving radioactive material for which remediation efforts were successful; surveys for ambient radiation exposure rate; reports, inspection, violation, follow-up records and reports, source implant and removal surveys, and copies of patient release. Retain 3 year(s) after event Confidential Destruction 9/11/2025
200937 Radioactive Material: User Applications This series documents applications and approvals for users of radioactive material. This series may include, but is not limited to: applications for principal investigator (PI), authorized user, authorized medical physicist, qualified user, and general user, authorization amendment forms, Radiation Safety Committee letters of approval to work with radioactive material, notebooks documenting each PI's permissions to use radioactive materials, and decommissioned lab notebooks. Retain 5 year(s) after event Confidential Destruction 9/11/2025
200938 Radioactive Material: Waste Disposal This series documents disposal of licensed radioactive material. This series may include, but is not limited to: planned and past releases, Sewer Release Monthly Summaries, Department of Transportation solid waste uniform manifests, waste tickets, and waste inventories. Retain 3 year(s) after termination Confidential Destruction 9/11/2025
200939 Reportable Disease Surveillance and Investigation Records This series documents the reporting, tracking, and resolution of possible communicable disease problems. This series may include, but is not limited to: surveillance reports, reporting forms, morbidity forms, death certificates, case investigation files, laboratory and other reports. Retain 10 year(s) after last action Confidential Destruction 9/11/2025
200940 Sanitation Records This series documents general environmental, sanitation and health condition testing and remediation efforts, such as vector-borne disease control and rodent abatement. This series may include, but is not limited to: logs, reports, and sanitary surveys Retain 3 year(s) after end of calendar year Non-confidential Destruction 9/11/2025
200941 School Health Program Records This series documents the health district's relationship with local school districts through school health clinics, performance of staff visits to schools for training, public education, and health screenings. This series may include, but is not limited to: program records, logs, and ledgers. Retain 5 year(s) after end of academic year Confidential Destruction 9/11/2025
200942 Senior Programs: Non-Medical This series documents staff participation in various seniors programs, including Older Americans Act programs. This series may include, but is not limited to: contact records, training programs, health screenings, immunization clinics, and day care and nursing home placement. Retain 5 year(s) after end of calendar year Confidential Destruction 9/11/2025
200943 Services to Clients: Non-Medical This series documents interaction with clients in a non-medical capacity, such as providing services, training and educational programming for: infant and baby care, children or youth programs, family planning and pre-conception education, home health contacts, expectant families and pre-natal care, personal care hygiene training, lead poisoning prevention, school health programs, health insurance options, and seniors' programs. This series does not include information that is filed in the patient medical record. This series may include, but is not limited to: training and programming records, client files, and referrals. Retain 5 year(s) after last action Confidential Destruction 9/11/2025
200944 Sexual Assault Records: Adults This series documents the services provided to adult survivors of sexual assault. This series may include, but is not limited to: medical evaluations, laboratory tests, examination results, and prescriptions. Retain 20 year(s) after creation Confidential Destruction 9/11/2025
200945 Sexual Assault Records: Minors This series documents the services provided to minor survivors of sexual assault. This series may include, but is not limited to: forensic medical evaluations, laboratory tests, examination results, and prescriptions. Retain 38 year(s) after birth Confidential Destruction 9/11/2025
200946 Transplant Records This series documents the receipt and disposition of donated organs and tissue for transplantation from one patient to another. This series may include, but is not limited to: acquisition and disposition documentation, and donor information. Retain 10 year(s) after end of calendar year Confidential Destruction 9/11/2025
200947 Tuberculosis: Evaluation for Presence of Tuberculosis Infection or Disease in Persons with Exposure to Rifampin-Resistant Source - Not Treated: Adults This series documents screening and testing for the presence of tuberculosis in adults who were exposed to a source case with rifampin-resistant tuberculosis disease and either had negative evaluation results or treatment for them was not recommended but does not include those who received treatment. This series may include, but is not limited to: skin test results and contact histories. Retain 20 year(s) after last action Confidential Destruction 9/11/2025
200948 Tuberculosis: Evaluation for Presence of Tuberculosis Infection or Disease in Persons with Exposure to Rifampin-Resistant Source - Not Treated: Minors This series documents screening and testing for the presence of tuberculosis in minors who were exposed to a source case with rifampin-resistant tuberculosis disease and either had negative evaluation results or for whom treatment was not recommended, but does not include those who received treatment. This series may include, but is not limited to: skin test results and contact histories. Retain 38 year(s) after birth Confidential Destruction 9/11/2025
200949 Tuberculosis: Evaluation for Presence of Tuberculosis Infection or Disease in Persons Without Exposure to Rifampin-Resistant Source - Not Treated: Adults This series documents screening and testing for the presence of tuberculosis in adults. who either had negative evaluation results or for whom treatment was not recommended but does not include those who were treated or evaluated due to potential exposure to a rifampin-resistant source case. This series may include, but is not limited to: skin test results and contact histories. Retain 10 year(s) after last action Confidential Destruction 9/11/2025
200950 Tuberculosis: Evaluation for Presence of Tuberculosis Infection or Disease in Persons Without Exposure to Rifampin-Resistant Source - Not Treated: Minors This series documents screening and testing for the presence of tuberculosis in minors who had negative evaluation results or for whom treatment was not recommended, but does not include those who were treated or evaluated due to potential exposure to a rifampin-resistant source case. This series may include, but is not limited to: skin test results and contact histories. Retain 28 year(s) after birth Confidential Destruction 9/11/2025
200951 Tuberculosis: Treatment for Tuberculosis Infection or Disease - Not Rifampin-Resistant: Adults This series documents the screening, testing and treatment of adults diagnosed with active tuberculosis disease or latent tuberculosis infection, and includes those who received treatment due to exposure, but not those who were evaluated and treated for rifampin-resistant disease. This series may include, but is not limited to: skin-test results, contact histories, x-rays, and treatment records. Retain 20 year(s) after last action Confidential Destruction 9/11/2025
200952 Tuberculosis: Treatment for Tuberculosis Infection or Disease - Not Rifampin-Resistant: Minors This series documents the screening, testing and treatment of minors diagnosed with active tuberculosis disease or latent tuberculosis infection, and includes those who received treatment due to exposure, but not those who were evaluated and treated for rifampin-resistant disease. This series may include, but is not limited to: skin test results, contact histories, x-rays, and treatment records. Retain 38 year(s) after birth Confidential Destruction 9/11/2025
200953 Tuberculosis: Treatment for Tuberculosis Infection or Disease - Rifampin-Resistant: Adults and Minors This series documents the screening, testing and treatment of adults and minors diagnosed with rifampin-resistant active tuberculosis disease. This series may include, but is not limited to: skin test results, contact histories, x-rays, and treatment records. Retain 50 year(s) after last action Confidential Destruction 9/11/2025
200954 Virginia Newcomer Health Program Records This series documents the certification of eligibility for and provision of initial health screenings to newly arrived refugees and other qualified individuals as part of the Virginia Newcomer Health Program. This series also documents the identification and intervention of communicable diseases and other conditions of public health concern. This series may include, but is not limited to: eligibility documentation, client files, encounter forms, data collection forms, and test results. Retain 5 year(s) after last action Confidential Destruction 9/11/2025
200955 Vital Records: Copies of Death Certificates Retained by Local Health Districts This series documents true and complete copies of death certificates retained by local health districts that are used for the issuance of certified copies by the county or city registrar. This series may include, but is not limited to: certificates Retain 5 year(s) after end of calendar year Confidential Destruction 9/11/2025
200956 Water Testing Records This series documents the testing of water samples, such as beach monitoring and dialysis center testing, but excludes drinking water. This series may include, but is not limited to: test results, logs and reports. Retain 3 year(s) after end of calendar year Non-confidential Destruction 9/11/2025
200957 Women's, Infant's and Children's (WIC) Records This series documents staff and client participation in the Women's, Infant's and Children's (WIC) program to provide nutritional support and supplements. This series may include, but is not limited to: client files, program records and referrals. Retain 3 year(s) after end of calendar year Confidential Destruction 9/11/2025