Can a Doctor Destroy Your Records?

J Greene

Q: Can my physician destroy my medical records if I haven’t been to see him in seven years? He is still my doctor, I just haven’t needed to see him in that time. I have been told that my records have been destroyed and that I have no medical history from him. How can they do this without even notifying me?

A: Your sad tale is a reminder to everyone to regularly request copies of medical records from doctors you’ve seen. You never know what might happen to them, as in your case. So don’t depend on your doctor’s willingness to pay for storing them over the long run.

      There are many good reasons to become the "guardian" of your own medical information. There's the simple issue of having test results that establish a base line, to which later tests can be compared. For instance, a woman's first mammogram can be used to identify benign growths that don't need to be biopsied again in the future. Or what if you take a drug that is later related to health problems, like the women who took DES during their pregnancies in the 1960s — their daughters and possibly even granddaughters are still feeling the effects of that drug. The only way to know if they're exposed is to look back in the records.
      As for the appropriateness of your doctor's conduct, it's possible that he broke a state law or at least an ethical one. Each state has its own rules on retaining certain medical records. You could find out for sure by checking the state health department, the state medical society or the local affiliate of the American Health Information Management Association (AHIMA); you can find the local branch at the national group's Web site.
      But beyond the law, there's also doing the right thing. "I would find it reprehensible for a physician not to have the medical records of someone he has seen just seven years before," says Dr. Vincent Riccardi, who runs American Medical Consumers, which helps patients resolve problems with the medical system. "Most medical problems are chronic," Dr. Riccardi adds; seven years isn't long enough to follow a long-term health issue.
      At the very least, your doctor should have given you the chance to claim the records before they were dumped. That's what the American Medical Association (AMA) recommends to its members. And most doctors will hold onto their patients' records until they close the practice or the patient has died, especially physicians who work on their own. Large group practices that are inundated with paperwork may have a more formal, regular purging process. It wouldn't hurt to check with your doctor's office on their policy.
      There's a group of professionals who specialize in this very area — medical record keeping. AHIMA has its own recommended retention standards, which are based on what many state laws say. Those standards — geared more toward hospitals than doctors — say that some records should never be thrown away, such as a master list of patients seen, births, deaths and surgical procedures performed. The AMA says immunization records should never be destroyed.
      Beyond that, the record-keeping pros recommend that a patient's chart be held for at least 10 years after the most recent visit. And there are some special records that should be kept even longer — for instance, fetal heart-monitor records should be held for about 28 years after the baby's born. (Most likely, this recommendation has more to do with malpractice suits than following the child's health.)
      Unfortunately for you, once your records are shredded, there's not much you can do. Just start a comprehensive medical file at home and start requesting information from all the doctors you've seen. American Medical Consumers has an information packet that can help; check out the group's Web site.
      All of this turmoil over reams of paper should start to subside in the future, as more and more patient records are switched over to computers. Much of the information is already electronic — when you go to the hospital, they start digitizing you from the moment you walk in the door. Increasingly, big facilities (hospitals and large medical groups) are using intranet systems to share information within the hospital or with doctors who regularly practice there. The doctor can go to any terminal and pull up your medical information. New hospitals being designed today are including space for such information terminals at each bedside.
      Still, the Holy Grail of an electronic patient record has not yet arrived, in part because of the difficulty of getting different computer systems used by doctors, hospitals, nursing homes and insurance companies to talk to each other. There's also the issue of confidentiality: The technogeeks are looking to the Internet as a place to store medical records and get around the compatibility question, but there's the obvious concern that hackers could get past pretty much any encryption system. Of course, who would want to look up the details of some stranger's colon polyp removal?
      In any event, the moral of the story is simple: Get your medical records before they end up as long, thin strips in the Dumpster behind your doctor's office.

                                                                                   
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