University Records Center
Health System Administration Records
Office of Audit & Compliance, Office of the General Counsel, and the University Archives and Records Center (Effective January 2, 2001)
Formally Adopted by the President’s Advisory Committee on the University Archives and Records Center (April 11, 2002)
Formally Adopted by Resolution of the Trustees of the University of Pennsylvania (June 17, 2011)
| Quality Improvement |
| Quality improvement outcome database, except peer review |
permanent |
| Quality improvement records — peer review |
7 years |
| Medical staff records |
75 years |
| Impaired physician/clinician records |
75 years |
| Housestaff |
| Housestaff evaluations |
7 years |
| Other housestaff records |
75 years |
| Regulatory Records |
| Accreditation records |
permanent |
| Certificate of need (CON) records and determinations of non-reviewability |
permanent |
| Hospital service licensure records |
permanent |
| Surveys, deficiency citations and related plans of correction |
permanent |
| Records of waivers from standards |
permanent |
| Reports to licensing boards |
permanent |
| Risk and claims management records/incident reports/accident/loss reports/expense records |
7 years |
| Health System policies and procedures |
10 years after withdrawal/revision |
| Reports of formal complaints, grievances, investigations and dispositions |
4 years |
| Miscellaneous |
| Pharmaceutical assistance contracts for the elderly |
7 years |
| Cost Reports/Claims under Medicare, Medicaid, or other third-party payers |
4 years from closing of cost report |
| Dietary Service |
| Dietary service records |
4 years |
| Nursing Service |
| Nursing patient assignment records |
7 years |
| Minutes of nursing administration staff meetings |
5 years |
| Nursing time/attendance schedules |
7 years |
| Nursing policies and clinical procedures |
10 years |
| Pharmacy Service |
| Pharmacy records |
7 years |
| Records of serious, unexpected adverse drug experiences from prescription drugs for human use without approved new drug applications |
10 years |
| Laboratory, Pathology and Blood Services |
| Laboratory records, unless otherwise specified |
4 years |
| Clinical laboratory permit |
permanent |
| Immunohematology and tranfusion test and reports |
5 years |
| Blood and blood quality control and testing records |
later of 5 years after processing records are completed or 6 months after expiration; permanent if no expiration |
| Policies to insure positive identification of a blood or blood product recipient |
10 years |
| Certification of good health of donors for manufacture of Plasma Cryoprecipitated AHF or Source Plasma |
7 years |
| Complaints of adverse reactions regarding each unit of blood or blood production arising as a result of blood collection or transfusion |
7 years |
| Written report of investigations of each reported adverse blood collection or transfusion reaction |
7 years |
| Blood bank compatibility records |
7 years |
| Records or remedial actions taken to prevent future recurrences or transfusion reactions |
7 years |
| Copy of blood donor registry sent to blood bank by PA Dept. of Health |
most recent |
| Written procedures for collection, processing, compatibility testing, storage and distribution of blood and blood components for homologous transfusion, autologous transfusion and further manufacturing purposes |
10 years |
| Manual of standard operating procedures and methods for blood collecting and transfusion |
10 years |
| Manufacturing records of biological products licensed by Secretary of HHS |
later of 5 years after records of manufacture completed or 6 months after the latest expiration date for individual product |
| Record of name and qualifications of person immediately in charge of employees who determine suitability of donors or collect blood when a physician is not present on the premises |
7 years |
| Records related to blood collection, processing, compatibility testing, storage and distribution |
later of 5 years after the records of processing have been completed or 6 months after the latest expiration date for the individual product. When there is no expiration date, records shall be retained indefinitely |
| Cytology slide preparations not loaned to proficiency testing programs |
permanent |
| Pathology test reports |
permanent |
| Written procedures for reporting imminent life-threatening laboratory results or panic values |
permanent |
| Records of laboratory/pathology equipment maintenance and function checks |
life of equipment |
| Premalignant and malignant section slide preparations |
permanent |
| Histopathology stained slides |
permanent |
| Histocompatibility records |
permanent |
| Autopsy records |
permanent |
| Clinical, surgical, pathology and cytology records |
permanent |
| Radiology and Nuclear Medicine Services |
| Radiology records of current inspections by radiation health specialists |
4 years |
| Mammogram records |
10 years |
| Radiology records, films, scans and other image records |
7 years |
| Nuclear medicine; radioisotope records |
permanent or until authorized by Nuclear Regulatory Commission for disposal |
| Nuclear medicine instrument log books |
life of instrument |
| Nuclear medicine annual accumulation records on personnel |
becomes part of personnel file |
| Nuclear medicine patient records (department duplicate of medical record) |
4 years |
| Copies of reports of nuclear medicine interpretations, consultations, and procedures and disposition of pharmaceuticals |
7 years |
|
|
| Rehabilitation Service Records, Except Quality Improvement |
|
Rehabilitation Service Records, Except Quality Improvement
|
4 years
|
| Special Care Unit |
| Special care unit records, except quality improvement |
4 years |
| Emergency Service(Dedicated Emergency Departments) |
| Emergency service records and logs, except quality improvement |
7 years |
| Central logs for Dedicated Emergency Departments |
7 years |
| Emergency patient care policies and procedures |
10 years |