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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 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
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