Can a Doctor Destroy Your Records?
Q: Can my physician destroy my medical
records if I havent been to see him in seven years? He is still my doctor, I just
havent 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
A: Your sad tale is a reminder to everyone
to regularly request copies of medical records from doctors youve seen. You never
know what might happen to them, as in your case. So dont depend on your
doctors 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
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
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
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