If the patient was less than 18 years of age on his/her last date of service, the record must be kept until he/she reaches age 18 plus 5 years, or 10 years whichever is the longer time period.*
If the patient was 18 years of age or older on his/her last date of service, the record must be kept for 10 years from the last date of service. *
* For all patients (without regard to age), the immunizations (other than influenza), positive Purified Protein Derivative (PPD)s and any patient record with documentation of Tuberculosis (TB) infection or disease treatment must be kept permanently.
Note: If information on completed/ recommended treatment regimen, allergies, and sensitivities, regarding TB, is extracted and entered on the permanent immunization/master record, the record may be destroyed when it reaches the assigned retention period.
Master Patient Index
The Master Patient Index is the locator system for the medical records and is to be kept permanently. It shall be all-inclusive to contain the name and location of all active, inactive and destroyed patient records. When the record is removed from the active file, a notation on the index shall indicate where the record is and if the record is reactivated, a notation is to be made. If the record meets the retention period and is destroyed, a note is to be included to indicate the record was destroyed and the date of destruction.
Procedures for Archiving
Following are procedures to use in archiving medical records in accordance with the December, 2001 Records Retention Schedule:
The medical records retention schedule is based on three factors:
(1) The last date of service; (2) patient’s age (minor – less than 18 years of age and adult – 18 years of age and older); and (3) type of service the patient has received, i.e., Immunizations and positive tuberculosis (TB) test and TB infection or disease treatment.
The record retention criteria necessitate the date of birth being included on the label of the folder.
When the patient has not received a service within the past five years, the record is considered inactive and may be removed from the active files.
In establishing the inactive files, consider the following:
Minor patient records;
Adult patient records; and
Location of Inactive/Archived Records
Local health departments are responsible for the storage of inactive/archived records. The records must be stored in an orderly, accessible manner and in a secure location. The State Archives Center may not be used for storing local health department records.
Inactive/ Archived Records and/or Reports may be retained in electronic formats to provide a better source of storage to local health departments. The access should be easy, fast, and readily available when needed. The inactive/archived records and/or reports should be maintained according to the records retention schedule and properly disposed of once the retention period has ended.
Destruction of Medical Records
If the medical record has met the required retention period, it should be destroyed. To destroy the record, it must be burned or shredded. A Records Destruction Certificate (Form PRD-50) is to be completed and mailed to the Department for Libraries and Archives, 300 Coffee Tree Road, Frankfort, Kentucky 40602. The PRD-50 forms may be obtained from the Department for Public Health Record Officer, Administration and Financial Management Division, phone number 502-564-7213. A copy of the Destruction Certificate is to be permanently maintained at the local health department.
LOCAL HEALTH DEPARTMENT RECORDS RETENTION SCHEDULE
See the link below for the most up-to-date KDLA Local Health Records Retention Schedule.
Includes purchasing, storage, inventory, dispensing, and reporting of medication errors; and
Is consistent with the Department for Public Health, Board of Pharmacy and other relevant laws and guidelines.
Only additional in-house medications that are specific to the Local Health Department must be included in their Medication Policy. Medications listed throughout the CCSG need only be referenced in their local policy as “all medications listed in the CCSG.”
II. CHFS legal counsel has advised that LHDs prescribing drugs not in the CCSG assume responsibility specific to the service being provided and do so under local authority and individual licensees (physicians, nurse practitioners, etc.) without the specific endorsement by or liability to CHFS or DPH. The LHD also assumes responsibility for conforming to pharmacy and other relevant statutes.
III. Definitions and additional guidelines for nurses regarding medication prescribing, dispensing, delivering, and administering*:
A. Prescription means an authorization to obtain a prescription drug.
This authorization can be given to a pharmacist via piece of paper or telephone call.
An MD, PA, or an APRN (within their scope of licensed practice and collaborative agreements) may authorize a prescription.
Dispense means to give a patient a drug to consume or use later.
The drug must be packaged, labeled and recorded according to the Pharmacy Law.
Dispensing is legal for RNs and APRNs only in LHDs following the CCSG and the DPH approved drug lists.
Dispensing of sample drugs within their scope of practice is legal only for APRNs.
C. Administer means to put a drug into a patient’s body.
This can occur by giving an injection, oral medication, applying a cream or ointment, or use of an inhaler.
2. Administration of a single dose is legal for LPNs, RNs, and APRNs upon the authorization of an MD or APRN.
D. Deliver means hand over a previously dispensed drug.
LPNs and unlicensed personnel may deliver meds that have been properly dispensed.
It is recommended that this be done in the LHD under the delegated authority of an APRN or RN.
For DOT guidelines, see TB section in the CCSG.
* 1. Also included are other brands or generic forms of medications containing identical amounts of the same active drug ingredient in the same dosage form (this needs to be considered).
2. Dosages may be adjusted based on weight and age.
3. For DOT Guidelines, see TB section in the CCSG.
4. Before crushing or giving any medicaton mixed with food, check with the prescribing clinician for instructions.
At present, the only approved medical abbreviations that are acceptable for LHD documentation are in this sectionand Marilyn Fuller Delong’s Medical Acronyms, Eponyms & Abbreviations, 3rd Edition or later. The following list has been compiled from sources that are nationally acceptable and are taken from documents that are published by such agencies as the Centers for Disease Control and Prevention, medical references, the MERCK Manual, and medical dictionaries such as Dorland’s Medical Dictionary. Each LHD should keep a log of non-medical abbreviations that are used in their agency, such as MCHS – Madison County High School, Tues. – Tuesday, CBH – Central Baptist Hospital, etc.
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
2 times a day
3 times a day
4 times a day
1st heart sound
2nd heart sound
3rd heart sound
4th heart sound
Ask, Advise, Assess, Assist, Arrange
Abdominal pain, Chest pain, Headaches, Eye problems, Severe leg pain