/policies/,/policies/administrative/,/policies/administrative/uw-health-administrative/,/policies/administrative/uw-health-administrative/health-information-management/,

/policies/administrative/uw-health-administrative/health-information-management/626.policy

201611335

page

100

UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Health Information Management

Medical Record Retention (6.26)

Medical Record Retention (6.26) - Policies, Administrative, UW Health Administrative, Health Information Management

6.26

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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).
Policy Title: Medical Record Retention
Policy Number: 6.26
Effective Date: December 1, 2016
Chapter: Health Information Management
Version: Revision
I. PURPOSE

To provide for the retention of medical records required to support the UW Health mission of advancing
health without compromise through service, scholarship, science, and social responsibility.

II. POLICY ELEMENTS

Medical records shall be retained on all patients treated at UW Health.

III. PROCEDURE

A. Documentation of patient care will be entered directly into the electronic medical record, dictated
or documented on approved paper forms. The goal of UW Health is to have new records
maintained in the electronic record and to maximize direct entry into the electronic medical
record. Documentation of patient care should be made directly into the electronic medical record
unless an exception for continued use of a paper record has been approved by the Medical
Records Committee or the Director, Health Information Management (HIM) Department or
designee.
B. Paper records that are scanned into the electronic medical record will be maintained for a
minimum of 30 days and then confidentially destroyed.
C. Electronic medical records will be maintained on a permanent basis.
D. Original records of University Hospitals remaining on paper will be maintained at the State
Records Center on a permanent basis.
E. Original records of UW Medical Foundation remaining on paper will be maintained at an off-site
location on a permanent basis.
F. The HIM Department will maintain and operate a system to request and return paper medical
records to the HIM Department as needed.
G. Paper medical records retrieved from the State Records Center or off-site location for patient care
purposes will be scanned into the electronic medical record upon request.






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IV. COORDINATION

Sr. Management Sponsor: SVP, Chief Information Officer
Author: Director, Health Information Management

Approval Committee(s): Medical Record Committee; UW Health Administrative Policy & Procedure
Committee

SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer

Revision Detail

Previous revision: 112013
Next revision: 122019