Local Schedule HR
Retention Schedule for Records of Public Health Agencies
Effective November 1, 1994
Preface
This schedule establishes mandatory minimum retention periods
for the records listed. No local government office may dispose of
a record listed in this schedule prior to the expiration of its
retention period. A records control schedule of a local government
may not set a retention period for a record that is less than that
established for the record on this schedule. The originals of records
listed in this schedule may be disposed of prior to the expiration
of the stated minimum retention period if they have been microfilmed
or electronically stored pursuant to the provisions of the Local
Government Code, Chapter 204 or Chapter 205, as applicable, and
rules of the Texas State Library and Archives Commission adopted
under authority of those chapters. Actual disposal of such records
by a local government or an elective county office is subject to
the policies and procedures of its records management program.
Destruction of local government records contrary to the provisions
of the Local Government Records Act of 1989 and administrative rules
adopted under its authority, including this schedule, is a Class
A misdemeanor and, under certain circumstances, a third degree felony
(Penal Code, Section 37.10). Anyone destroying local government
records without legal authorization may also be subject to criminal
penalties and fines under the Open Records Act (Government Code,
Chapter 552).
Introduction
The Government Code, Section 441.158, provides that the Texas
State Library and Archives Commission shall issue records retention
schedules for each type of local government, including a schedule
for records common to all types of local government. The law provides
further that each schedule must state the retention period prescribed
by federal or state law, rule of court, or regulation for a record
for which a period is prescribed; and prescribe retention periods
for all other records, which periods have the same effect as if
prescribed by law after the records retention schedule is adopted
as a rule of the commission.
Local Schedule HR sets mandatory minimum retention periods for
records series (identified in the Records Series Title column) commonly
found in local health units and departments, public health districts,
local public hospitals, animal control departments, animal shelters
owned and/or operated by local governments, and the office of county
inspector of hides and animals. If the retention period for a record
is established in a federal or state law, rule of court, or regulation,
a citation to the relevant provision is given; if no citation is
given, the authority for the retention period is this schedule.
The retention period for a record applies to the record regardless
of the medium in which it is maintained. Some records listed in
this schedule are maintained electronically in many offices, but
electronically stored data used to create in any manner a record
or the functional equivalent of a record as described in this schedule
must be retained, along with the hardware and software necessary
to access the data, for the retention period assigned to the record,
unless backup copies of the data generated from electronic storage
are retained in paper or on microfilm for the retention period.
Unless otherwise stated, the retention period for a record is
in calendar years from the date of its creation. The retention period,
again unless otherwise noted, applies only to an official record
as distinct from convenience or working copies created for informational
purposes. Where several copies are maintained, each local government
should decide which shall be the official record and in which of
its divisions or departments it will be maintained. Local governments
in their records management programs should establish policies and
procedures to provide for the systematic disposal of copies.
If a record described in this schedule is maintained in a bound
volume of a type in which pages are not designed to be removed,
the retention period, unless otherwise stated, dates from the date
of last entry. If two or more records listed in this schedule are
maintained together by a local government and are not severable,
the combined record must be retained for the length of time of the
component with the longest retention period. A record whose minimum
retention period on this schedule has not yet expired and is less
than permanent may be disposed of if it has been so badly damaged
by fire, water, or insect or rodent infestation as to render it
unreadable, or if portions of the information in the record have
been so thoroughly destroyed that remaining portions are unintelligible.
If the retention period for the record is permanent on this schedule,
authority to dispose of the damaged record must be obtained from
the director and librarian of the Texas State Library. The Request
for Authority to Destroy Unscheduled Records (Form SLR 501) should
be used for this purpose.
Requests for Authority to Destroy Unscheduled Records (SLR 501),
whose submission to the director and librarian of the Texas State
Library is required by the Local Government Code, Section 203.045,
need not be filed for records shown as exempt from the requirement.
Certain records listed in this schedule are assigned the retention
period of AV (as long as administratively valuable). This retention
period affords local governments the maximum amount of discretion
in determining a specific retention period for the record described.
Although AV may be used as a retention period on a records control
schedule of a local government, it is in the best interests of any
records management program that fixed retention periods be assigned
for each records series. AV records tend to accumulate and go unmanaged.
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Abbreviations Used In This Schedule
AV - As long as administratively valuable
CFR - Code of Federal Regulations
FE - Fiscal year end
TAC - Texas Administrative Code
US - Until Superseded
Table of Contents
Part 1: Records Common to Public
Health Agencies
Part 2: Records of Local Public
Health Authorities
Section 2-1: Medical Records
Section 2-2: Inspection and Permit Records
Section 2-3: Miscellaneous Records
Part 3: Records of Local Public Hospitals
Section 3-1: Medical Records
Section 3-2: Laboratory and Therapy Records
Section 3-3: Miscellaneous Records
Part 4: Vital Statistics Records
Part 5: County Indigent Health Care Records
Part 6: Animal Control and Health Records
Part 7: Records of the County Inspector of Hides and Animals
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Records of Public Health Agencies
Retention Note: a) The term "public health agency"
means any local health department or unit, public health district,
local public hospital, animal control department, animal shelter
owned and/or operated by a local government, and the office of
county inspector of hides and animals.
b) For records of county medical examiners and emergency medical
services agencies, and for emergency communications records, see
Local Schedule PS (Records of Public Safety Agencies).
c) For administrative, financial, personnel, and support services
records not included in this schedule, see Local Schedule GR (Records
Common to all Governments).
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Part 1: Records Common to Public Health Agencies
Retention Note: This part provides retention periods for
records common to two or more of the public health agencies included
in this schedule.
4750-01 Appointment Records. RETENTION: AV. (Exempt from
destruction request requirement)
4750-02 Grant Records - All records and supporting documentation
necessary to disclose the services provided and financial management
of the grant.
a) Women, infants, children (WIC). RETENTION: 3 years following
the date of the submission of the final expenditure report for
the period to which the report pertains. [By regulation - 7 CFR
246.25(a)(2).]
Retention Notes: a) If any litigation, claim, negotiation,
audit, or other action involving the records has been started
before the end of the three-year period, the records must be
kept until all issues are resolved, or until the end of the
regular three-year period, whichever later.
b) Records of non-expendable property acquired in whole or
in part with WIC program funds must be retained for 3 years
after its final disposition.
b) Title XX family planning. RETENTION: 5 years from the date
of the service, or until all audit questions are resolved, whichever
later. [By regulation - 25 TAC 56.607(b) and 25 TAC 29.4.]
c) Early childhood intervention (ECI).
1. All necessary records and claims to fully document the services
and supplies provided. RETENTION: 5 years from the date of service
or until all audit questions, appeal hearings, investigations,
or court cases are resolved, as applicable. [By regulation -
40 TAC 31.408.]
2. All records pertaining to the financial management of the
grant. RETENTION: 5 years from the date of submission of the
annual or final report or until all audit questions are resolved,
whichever later. [By regulation - 25 TAC 621.26(b)(3).]
d) Other grants funded through Medicaid. RETENTION: 5 years
from the date of the service or until all audit questions are
resolved, whichever later. [By regulation - 25 TAC 29.4.]
e) Other federal grants and cooperative agreements such as community
health services projects, project grants for genetic diseases
testing and counseling programs, hemophilia treatment centers,
etc. RETENTION: 3 to 7 years or until resolution of all issues
arising from claim, negotiation, audit, or other actions. See
retention note.
Retention Note: To determine the retention period, see
Retention Note (b) to Part 2: Financial Records in Local Schedule
GR (Records Common to All Governments).
4750-03 Medical Waste Management Records
a) Records of on-site treatment by generator of medical waste
(animal waste, bulk human blood and blood products, microbiological
waste, pathological waste, and sharps) including date of treatment,
amount of waste treated, method/conditions of treatment, person
performing treatment, and written procedures. For incinerators
the hours of operation and all monitoring and testing results
are also required. RETENTION: 2 years. [By regulation - 30 TAC
111.127(b) for operators of on-site medical waste incinerators,
and by authority of this schedule for all other types of treatment.]
b) Waste shipment records maintained by the generator of medical
waste such as waste shipping control tickets, tracking forms,
exception reports, shipment logs, and receipts from the transporter
documenting the weight of waste collected and date of collection.
RETENTION: 3 years. [By regulation - 30 TAC 330.1004(h)(4).]
4750-04 Medicare Records - Billing and cost report materials.
RETENTION: 5 years after the month the cost report is filed. [By
regulation - Medicare Hospital Manual, HIM-10, Sec. 413 (B) [Rev.
No. 572].]
4750-05 Operational Permits, Licenses, and Certifications
- Permits, licenses, and certifications from the Texas Department
of Health or other government agencies as required by law or regulation
for the operation of local government owned laboratories, clinics,
or other health-related facilities; and any reports, correspondence,
or other documentation bearing directly on the application for,
the issuance of, or the renewal of the permit, license, or certificate.
RETENTION: Expiration or cancellation + 3 years.
4750-06 Planning Records - Reports, studies, analyses,
projections, and other planning documents relating to the development
of local health, sanitary inspection, and environmental quality
programs and public hospitals. RETENTION: 5 years. (Before disposal
appraise for continuing administrative usefulness and historical
value. Those records relating to major development projects and
other records considered of historical value should be retained
permanently.)
4750-07 Radiation Control Records
a) Records showing the receipt, transfer, and disposal of all
licensed or registered sources of radiation. Documentation of
disposal should include waste shipping records, such as manifests
and receipts. RETENTION: Until disposal is authorized by the Texas
Department of Health. [By regulation - Standard 11.4, Texas Regulations
for Control of Radiation adopted by reference, 25 TAC 289.113.]
b) Records of radiation protection programs.
1. Documentation of the provisions of the program. RETENTION:
Until termination of license or certificate of registration.
[By regulation - Standard 21.1102(b), Texas Regulations for
Control of Radiation adopted by reference, 25 TAC 289.113.]
2. Audits and other reviews of program content and implementation.
RETENTION: 3 years. [By regulation - Standard 21.1102(b), Texas
Regulations for Control of Radiation adopted by reference, 25
TAC 289.113.]
3. Records at additional sites authorized by a licensee or
certificate of registration. RETENTION: Period specified for
the authorized activity. [By regulation - Standard 21.1102(c),
Texas Regulations for Control of Radiation adopted by reference,
25 TAC 289.113.]
c) Routine surveys, instrument calibrations, and package surveys.
RETENTION: 3 years. [By regulation - Standard 21.1103(a), Texas
Regulations for Control of Radiation adopted by reference, 25
TAC 289.113.]
d) Surveys used for dose determination; results of air sampling,
surveys, and bioassays; and results of measurements and calculations
used to evaluate the release of radioactive effluents to the environment.
RETENTION: Until termination of license or certificate of registration.
[By regulation - Standard 21.1103(b), Texas Regulations for Control
of Radiation adopted by reference, 25 TAC 289.113.]
e) Tests for leakage or contamination of sealed sources of radioactive
material. RETENTION: 5 years. [By regulation - Standard 21.1104,
Texas Regulations for Control of Radiation adopted by reference,
25 TAC 289.113.]
f) Cumulative occupational exposure history. RETENTION: Until
termination of license or certificate of registration. [By regulation
- Standard 21.1105, Texas Regulations for Control of Radiation
adopted by reference, 25 TAC 289.113.]
g) Records used to prepare TRC Form 21-2 or equivalent for the
Texas Department of Health. RETENTION: 3 years. [By regulation
- Standard 21.1105, Texas Regulations for Control of Radiation
adopted by reference, 25 TAC 289.113.]
h) Records of planned special exposures. RETENTION: Until termination
of license or certificate of registration. [By regulation - Standard
21.1106, Texas Regulations for Control of Radiation adopted by
reference, 25 TAC 289.113.]
i) Records of individual dose monitoring results, including
at least annual updates of TRC Form 21-3 or records containing
all the information required by TRC Form 21-3. RETENTION: Until
termination of license or certificate of registration. [By regulation
- Standard 21.1107(e), Texas Regulations for Control of Radiation
adopted by reference, 25 TAC 289.113.]
j) Records documenting compliance with the dose limit for individual
members of the public. RETENTION: Until termination of license
or certificate of registration. [By regulation - Standard 21.1108(b),
Texas Regulations for Control of Radiation adopted by reference,
25 TAC 289.113.]
k) Records of the disposal of licensed materials by discharge
into sanitary sewage or treatment by incineration. RETENTION:
Until termination of license or certificate of registration. [By
regulation - Standard 21.1109(b), Texas Regulations for Control
of Radiation adopted by reference, 25 TAC 289.113.]
l) Records of testing entry control devices for very high radiation
areas. RETENTION: 3 years. [By regulation - Standard 21.1110(b),
Texas Regulations for Control of Radiation adopted by reference,
25 TAC 289.113.]
m) Tests of protective equipment including aprons, gloves, and
shields. RETENTION: Until inspection by the Texas Department of
Health. [By regulation - Standard 32.10(d), Texas Regulations
for Control of Radiation adopted by reference, 25 TAC 289.116.]
n) Records of receipt, transfer, and disposal of radiation machines;
correspondence to and from the Texas Department of Health regarding
radiation machines' records of surveys, calibrations, spot checks,
maintenance, and modifications performed on radiation machines
after April 1, 1989. RETENTION: Until inspection by the Texas
Department of Health. [By regulation - Standard 32.10(e), Texas
Regulations for Control of Radiation adopted by reference, 25
TAC 289.116.]
o) Documentation of test calibrations to determine compliance
with the standards for human diagnostic x-ray systems (radiographic,
radiographic/fluoroscopic, dental, and computed tomography) including
any numerical readings and any corrections or repairs. RETENTION:
5 years. [By regulation - Standard 32.20(h), Texas Regulations
for Control of Radiation adopted by reference, 25 TAC 289.116.]
p) Images of spot checks for computed tomography (CT) x-ray
systems. RETENTION: Until a new dose measurement is performed.
[By regulation - Standard 32.41(c)(2)(iii), Texas Regulations
for Control of Radiation adopted by reference, 25 TAC 289.116.]
q) Records for mammography x-ray systems.
1. Quality assurance records for mammography systems including
annual review of quality assurance program, and documentation
of equipment monitoring, checks of quality control items, and
any necessary corrections. RETENTION: 2 years. [By regulation
- Standard 32.17(a)(1)-(3), Texas Regulations for Control of
Radiation adopted by reference, 25 TAC 289.116.]
2. Annual evaluation and quality control checks for mammography
systems performed by a licensed medical physicist. RETENTION:
7 years. [By law - Health and Safety Code, Section 401.424(a)(4)(C).]
3. Original mammograms. RETENTION: Until the earlier of a)
5 years; b) if additional mammography of the same patient is
not performed by the facility, 10 years; or c) at the request
of the patient, the original mammogram may be forwarded to another
medical institution. [By law - Health and Safety Code, Section
401.424(a)(4)(E)(i)-(iii).]
r) Records for therapeutic x-ray systems of less than 1 MeV.
1. Calibrations of the therapy system. RETENTION: 5 years.
[By regulation - Standard 32.60(c)(2)(vi), Texas Regulations
for Control of Radiation adopted by reference, 25 TAC 289.116.]
2. Spot check measurements and records of any necessary corrective
actions. RETENTION: 2 years. [By regulation - Standard 32.60(c)(3)(vi),
Texas Regulations for Control of Radiation adopted by reference,
25 TAC 289.116.]
s) Records for therapeutic x-ray systems of more than 1 MeV.
1. Calibrations of the therapy system and of the dosimetry
system. RETENTION: 5 years. [By regulation - Standard 32.70(c)(3)(vi),
Texas Regulations for Control of Radiation adopted by reference,
25 TAC 289.116.]
2.Spot check measurements and records of any necessary corrective
actions. RETENTION: 3 years.[By regulation - Standard 32.70(c)(4)(viii),
Texas Regulations for Control of Radiation adopted by reference,
25 TAC 289.116.]
t) Records and reports of misadministration of radionuclides.
RETENTION: 10 years. [By regulation - Standard 41.26(d)(4), Texas
Regulations for Control of Radiation adopted by reference, 25
TAC 289.121.]
4750-08 Reports to Government Agencies - Reports to local,
state, or federal agencies regarding any aspect of local public
health activities and programs except for those reports specified
elsewhere in this schedule.
a) Annual reports. RETENTION: PERMANENT.
b) Special reports that are not recapitulated in annual reports.
RETENTION: AV unless otherwise required by requester. (Exempt
from destruction request requirement)
c) Interim or periodic reports on a less than annual basis that
are recapitulated in an annual report or in a special report under
(b). RETENTION: 1 year. (Exempt from destruction request requirement)
4750-09 Special Projects and Research Documentation. RETENTION:
10 years after completion of research or project.
4750-10 Survey and Inspection Reports - Includes building
and fire inspections, and Joint Commission on the Accreditation
of Hospitals (JCAH) surveys. Does not include surveys for monitoring
radiation (see item number 4750-07). RETENTION: 3 years.
4750-11 Volunteer Services Files - Information about individual
volunteers and duties they perform. RETENTION: Termination + 2 years.
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Part 2: Records of Local Public Health Authorities
Retention Notes: a) In this part the term "local
health authority" means local health units, local health
departments, public health districts, and health personnel appointed
by municipalities and counties without organized local public
health departments or districts.
b) This part should not be used for the records of a hospital
owned, operated, or leased by a local government (see Part 3:
Records of Local Public Hospitals).
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Section 2-1: Medical Records
Retention Note: Records in this section have retention
periods based on recommendations of the Texas Department of Health
and must be destroyed by shredding, pulping, or burning (if allowed
by local ordinance).
4775-01 Communicable Disease Surveillance Forms- Copies
of surveillance forms completed by Texas Department of Health personnel
and maintained by local health authorities. RETENTION: 5 years past
last date encounter occurred or until patient reaches 21st birthday,
whichever later.
4775-02 Dental Records and Referrals. RETENTION: 5 years
past the last date on which service was given or until patient reaches
21st birthday, whichever later. [By regulation - 22 TAC 109.44(b)
for minimum retention required for dental records maintained by
dentist.]
Retention Note: Because of the use of these records for
identification purposes, the Texas Department of Public Safety
recommends dental records be maintained a minimum of 10 years.
4775-03 Immunization Record and Consent Forms
a) Adults. RETENTION: 10 years following end of calendar year
in which consent form was signed.
b) Minors. RETENTION: 21st birthday or 10 years following end
of calendar year in which consent form was signed, whichever later.
4775-04 Patient Records - Medical records, including laboratory
reports and master index to records, of persons treated in local
health programs and similar records created as the result of control
or surveillance measures instituted by a local health authority.
a) Adult health, child health, chronically ill and disabled children,
and communicable diseases. RETENTION: 5 years past the last date
on which service was given or until the patient's 21st birthday,
whichever later.
b) Family health. RETENTION: 5 years past the last date on which
service was given or until the patient's 21st birthday, whichever
later.
Retention Note: If records of several family members
are located in same file, retention period is based upon age
of youngest family member.
c) Family planning, including Title XX medical records. RETENTION:
5 years past the last date on which service was given or until
the patient's 21st birthday, whichever later.
Retention Notes: a) The retention period of records
that document the use of an I.U.D. will begin at the end of
the effective life of the IUD
b) The retention period of records that document the surgical
implantation of contraceptives will begin when the contraceptive
is exhausted.
d) Maternal health. RETENTION: 5 years past the last date on
which service was given or until the infant's 21st birthday, whichever
later.
e) Sexually transmitted diseases except syphilis. RETENTION:
5 years past the last date on which service was given or until
the patient's 21st birthday, whichever later.
Retention Note: All sexually transmitted disease records
containing positive syphilis test results must be maintained
until 5 years past the patient's death, if known; or 25 years
from last date of service, if not known.
f) Syphilis.
1. Positive test results. RETENTION: 5 years past the date
of patient's death, if known; or 25 years from last date of
service, if not known.
2. Negative test results. RETENTION: 5 years past the last
date on which service was given or until the patient's 21st
birthday, whichever later.
g) HIV/AIDS. RETENTION: 5 years past the date of patient's death,
if known; or 25 years from last date of service, if not known.
h) Tuberculosis (including x-rays). RETENTION: 5 years past
the last date on which service was given or until the patient's
21st birthday, whichever later.
Retention Note: X-rays showing significant abnormalities
may be given to the patient and/or another authorized person.
In such circumstances, the director and librarian of the Texas
State Library, by authority of the Local Government Code, Section
202.004(a), hereby consents to the return as a permitted exception
to the statutory prohibition against the alienation of local
government records.
i) Hansen's disease. RETENTION: PERMANENT.
4775-05 Screening Procedures- Microscopical, cultural,
serological, and other screenings and tests, performed in local
government owned laboratories or clinics, that do not become part
of the patient records of a local health program. If such tests
or screenings do become part of the patient records of a local health
program, they should be retained for the period listed for that
program under item number 4775-04.
a) Health risk appraisal; blood pressure screening; blood pressure
referral; vision, hearing, and speech; diabetics screening; syphilis
serology; gonorrhea; other laboratory screenings and tests. RETENTION:
5 years past the last date on which service was given or until
the patient's 21st birthday, whichever later.
b) HIV.
1. Anonymous test results. RETENTION: 60 days or given to clients.
(Exempt from destruction request requirement)
Retention Note: The director and librarian of the
Texas State Library, by authority of the Local Government
Code, Section 202.004(a), hereby consents to the return of
these test results to clients as a permitted exception to
the statutory prohibition against the alienation of local
government records.
2. Seropositive confidential test results. RETENTION: 5 years
after the patient's death, if known; or 25 years after seropositive
results, if not known.
3. Seronegative confidential test results. RETENTION: 5 years
past the last date of services or until the patient's 21st birthday,
whichever later.
c) Infant screening for genetic or metabolic disorders. RETENTION:
Until the patient's 21st birthday.
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Section 2-2: Inspection and Permit Records
4775-21 Citations, Notifications of Violations, and Warning
Notices - Copies of notifications or orders sent or given to owner,
agent, or occupant of a business or property or to person holding
a health permit to correct violations of state or local health laws,
including documents verifying that the violations have been corrected.
RETENTION: Verification of correction + 3 years.
4775-22 Environmental Pollution Control Tests - Pollutant
measurements for air, soil, water, etc. and similar records of environmental
quality testing except monitoring of the release of radioactive
effluents (see item number 4750-07). RETENTION: 3 years.
4775-23 Food Quality Test Reports - Food tests, milk analyses,
swab tests, and similar laboratory test reports relating to the
testing and screening of food and food handling and processing equipment.
RETENTION: 3 years.
4775-24 Inspection Logs - Logs, registers, or similar records
providing a chronological listing of sanitary evaluations performed.
RETENTION: 1 year. (Exempt from destruction request requirement)
4775-25 Permits and Licenses - Permits and licenses issued
by local health authorities relating to restaurants, taverns, food
handling, dairy products, frozen dessert products, meat, vending
machines, day care centers, home health care, nursing homes, environmental
health, and all other situations, activities, or persons required
to have local health permits pursuant to state law or regulation.
a) Applications for and copies of permits or licenses. RETENTION:
Expiration or revocation + 3 years for granted permits or licenses;
date of denial + 1 year for denied applications. (Denied applications
are exempt from destruction request requirement.)
b) Applications and authorizations for variances or exemptions
from licensing regulations. RETENTION: Expiration or revocation
+ 3 years for approved variances or exemptions; date of denial
+ 1 year for denied applications. (Denied applications are exempt
from destruction request requirement.)
c) Logs or reports of permits or licenses and variances or exemptions
issued. RETENTION: 1 year. (Exempt from destruction request requirement)
4775-26 Quarantine Records - Orders, notifications, warrant
copies, and similar records relating to the isolation, quarantine,
disinfection, or other control measures applied to persons, animals,
objects, structures, and land to halt the introduction, transmission,
and spread of communicable disease. RETENTION: 3 years after quarantine
lifted.
4775-27 Sanitary Evaluation Reports - Reports of sanitary
inspections carried out by local health authority personnel on restaurants,
taverns, dairies, food markets, hotels, motels, nursing homes, day
care centers, campgrounds, vending machines, and other facilities
or equipment as required by state law or regulation or by local
ordinance. RETENTION: 3 years.
4775-28 Weights and Measures Records - Field test reports,
follow-up reports, logs or reports of seals issued, and similar
records relating to the certification of weights and measures in
a local government. RETENTION: 3 years.
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Section 2-3: Miscellaneous Records
4775-41 Communicable Disease Reports (to Health Authority)
- Reports and supporting documentation of communicable diseases
received by local health authorities from physicians, dentists,
hospitals, school districts, or others as prescribed by law. RETENTION:
3 years.
Retention Note: If, pursuant to law or regulation, a health
authority institutes control procedures and a patient file is
established as the result of a communicable disease report use
retention periods for Health Program Patient Records (see item
number 4775-04).
4775-42 Communicable Disease Reports (to State) - Copies
of periodic or emergency communicable disease reports from local
health authorities to the Texas Department of Health. RETENTION:
3 years.
4775-43 Complaints - Reports of complaints received by
local health authorities from the public or from other local departments
or agencies regarding possible violations of local or state health
laws or regulations. RETENTION: Resolution or dismissal of the complaint
+ 3 years.
4775-44 Controlled Substance and Dangerous Drug Records
a) Controlled substance logs and inventories, including suppliers'
invoices and credit memos; biennial inventory of controlled substances
required by the Drug Enforcement Administration (DEA); reports
of theft or significant loss of controlled substances; reports
of surrender or destruction of controlled substances; Schedule
V nonprescription register book; DEA order form, and all copies
of each unaccepted or defective order form and any attached statements
or other documents. RETENTION: 2 years. [By regulation and by
law - 21 CFR 1304.04(a); Health and Safety Code, Section 481.067(a);
37 TAC 13.61(a); 37 TAC 13.64(g).]
b) Prescriptions records, including copy 2 of the triplicate
prescription form required to prescribe a controlled substance.
RETENTION: 2 years after the date of the initial dispensing or
the last refilling of the prescription, whichever later. [By regulation
and by law - Health and Safety Code, Section 481.075(f)(2); Health
and Safety Code, Section 483.023; 37 TAC 13.64(b)(1).]
Special Note: For prescription records maintained in
a data processing system, see 37 TAC 13.64 for specific requirements
related to records medium.
c) Records of each acquisition and each disposal of a dangerous
drug. RETENTION: 2 years after the date of the acquisition or
disposal. [By law - Health and Safety Code, Section 483.024.]
4775-45 Rural Health Care Clinics Certified for Participation
in Medicare - Patient health records including identification and
social data, evidence of consent forms, medical history, health
assessment; reports of physical examinations, diagnostic and laboratory
test results; physician's orders, reports of treatments and medications;
and signatures of the physician or other health care professionals.
RETENTION: 6 years from date of last entry. [By regulation - 42
CFR 491.10(c).]
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Part 3: Records of Local Public Hospitals
Retention Note: This section applies to hospitals owned,
operated, or leased by a county, municipality, hospital authority,
hospital district, or other political subdivision of the state.
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Section 3-1: Medical Records
4800-01 Birth and Death Records - Copies of birth and death
certificates sent to local registrars of vital statistics (see also
Part 4: Vital Statistics Records). RETENTION: AV. (Exempt from destruction
request requirement)
4800-02 Index to Patient Medical Records. RETENTION: PERMANENT.
4800-03 Logs and Registers - Includes logs (e.g., delivery
room, emergency room, surgery) and registers (e.g., tumor registry
files, trauma registers). RETENTION: 5 years.
4800-04 Patient Records - Medical records that include
patient identification data; medical history; reports of relevant
physical examinations; diagnostic and therapeutic orders; documentation
of appropriate informed consent; clinical observations, including
the results of therapy; reports of procedures, tests, and their
results, including laboratory, pathology, and radiology reports;
and conclusions at termination of hospitalization or evaluation/treatment.
Includes treatment records for emergency room. RETENTION: 10 years
past the last date on which service was given or until the patient's
20th birthday, whichever later. [By law - Health and Safety Code,
Section 241.103.]
Retention Note: The Texas Health and Safety Code specifies
that the hospital may not destroy medical records that relate
to any matter that is involved in litigation if the hospital knows
the litigation has not been finally resolved.
4800-05 Patient Transfer Memoranda - A copy of each memorandum
of transfer, retained by both the transferring and receiving hospitals
and filed separately from the patient's medical record in a manner
that will facilitate its inspection by the Texas Department of Health.
RETENTION: 5 years.
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Section 3-2: Laboratory and Therapy Records
Retention Note: This section is for laboratory, therapy,
and x-ray records that do not become a part of the patient records
of the hospital. If such tests, reports, screening, etc., do become
a part of the patient records, they should be retained for the
period listed under Patient Records (see item number 4800-04).
4800-21 Blood Bank Records - Documentation of all significant
steps in the collection, processing, compatibility testing, storage
and distribution of each unit of blood and blood components. RETENTION:
5 years after the records of processing have been completed or 6
months after the latest expiration date for the individual product,
whichever later. [By regulation - 21 CFR 606.160(d).]
Retention Note: When there is no expiration date, records
shall be retained indefinitely.
4800-22 Electrocardiograms (EKG). RETENTION: 10 years.
4800-23 Electroencephalograms (EEG). RETENTION: 5 years
for normal tracings; 10 years for abnormal tracings.
4800-24 Pathology Reports and Slides. RETENTION: 10 years.
4800-25 Radiological Services - Copies of reports and printouts;
films; scans, and other image records, as appropriate. RETENTION:
5 years. [By regulation - 42 CFR 482.26(d)(2).]
4800-26 Registers of Tests. RETENTION: 5 years.
4800-27 Requests for Tests. RETENTION: 5 years.
4800-28 Test Results - Test results that do not become
part of the patient records excluding those specified elsewhere
in this section. RETENTION: 3 months. (Exempt from destruction request
requirement)
4800-29 Therapy Treatment Records - Including consent forms.
RETENTION: 5 years.
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Section 3-3: Miscellaneous Records
4800-41 Admission and Discharge Reports. RETENTION: 3 years.
4800-42 Census Records of Patients. RETENTION: 10 years.
4800-43 Communicable Disease Reports to State and Local
Health Authorities. RETENTION: 3 years.
4800-44 Controlled Substance and Dangerous Drug Records
a) Controlled substance logs and inventories, including suppliers'
invoices and credit memos; biennial inventory of controlled substances
required by the Drug Enforcement Administration (DEA); reports
of theft or significant loss of controlled substances; reports
of surrender or destruction of controlled substances; Schedule
V nonprescription register book; DEA order form, and all copies
of each unaccepted or defective order form and any attached statements
or other documents. RETENTION: 2 years. [By regulation and by
law - 21 CFR 1304.04(a); Health and Safety Code, Section 481.067(a);
37 TAC 13.65(a); 37 TAC 13.64(g).]
b) Records of each acquisition and each disposal of a dangerous
drug. RETENTION: 2 years after the date of the acquisition or
disposal. [By law - Health and Safety Code, Section 483.024.]
c) Inpatient records - Original medication orders shall be maintained
with the medication administration record in the medical records
of the patient (see item number 4800-04). RETENTION: 10 years
past the last date on which service was given or until the patient's
20th birthday, whichever later. [By regulation and by law - 37
TAC 13.65(c)(2); Health and Safety Code, Section 241.103.]
d) Outpatient records - Prescriptions records, including copy
2 of the triplicate prescription form required to prescribe a
controlled substance. RETENTION: 2 years from the date of filling
or the date of the last refill dispensed. [By regulation and by
law - Health and Safety Code, Section 481.075(f)(2); Health and
Safety Code, Section 483.023; 37 TAC 13.64(b)(1); 37 TAC 13.65(b)(1).]
Special Note: For prescription records maintained in
a data processing system, see 37 TAC 13.64 for specific requirements
related to records medium.
4800-45 Dietary and Food Service
a) Food service records, including food costs, meal counts, and
dietary services studies. RETENTION: 5 years.
b) Menus. RETENTION: 2 years.
c) Rosters of patient diet orders. RETENTION: 2 months. (Exempt
from destruction request requirement)
4800-46 Housekeeping Room Records. RETENTION: 2 years.
4800-47 Infection Control and Monitoring Records. RETENTION:
10 years.
4800-48 Nuclear Medicine Services - Copies of nuclear medicine
reports and records of the receipt and disposition of radiopharmaceuticals.
RETENTION: 5 years. [By regulation - 42 CFR 482.53(d)(1).]
4800-49 Nursing Services Reports - Supervisory and staffing
records/reports. RETENTION: 5 years.
4800-50 Security Records
a) Incident reports. RETENTION: 5 years.
b) Daily log - Listing of notable occurrences. RETENTION: 2
years.
c) Lost and found log. RETENTION: After disposal of items +
2 years.
4800-51 Social Services Case Records- Documentation of
social services provided, other than what is filed in the medical
record. RETENTION: 5 years from the last date of service.
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Part 4: Vital Statistics Records
Retention Notes: a) This section applies to local health
authorities that serve as registrars of vital statistics.
b) The same records, if maintained by a justice of peace or
city clerk or secretary as a local registrar, are listed in Part
3 of Local Schedule LC (Records of Justice and Municipal Courts)
and are assigned the same item numbers as this section.
2400-01 Birth and Death Record (combination of the Birth
Record and Death Record). RETENTION: PERMANENT. [By law - Health
and Safety Code, Section 191.026.]
2400-02 Birth Record (Register of Births) - Recorded or
bound duplicate copies of birth certificates, delayed birth certificates,
or amended birth certificates. RETENTION: PERMANENT. [By law - Health
and Safety Code, Section 191.026.]
2400-03 Burial Transit Permit Records - Stubs, copies,
or lists of burial transit permits issued. RETENTION: 2 years.
2400-04 Death Record (Register of Deaths) - Recorded or
bound duplicate copies of death certificates, fetal death certificates,
or amended death certificates. RETENTION: PERMANENT. [By law - Health
and Safety Code, Section 191.026.]
2400-05 Disinterment Record
a) Copies of disinterment permits. RETENTION: PERMANENT.
b) Applications for permits. RETENTION: AV. (Obsolete record;
exempt from destruction request requirement)
2400-06 Notifications of Death of Persons Under 55 - Abstracts,
transcripts, or copies of death certificates from the Bureau of
Vital Statistics of persons under age 55 (or under 18 prior to May
1987), whose birth certificates are recorded in an office of a local
registrar. RETENTION: Until notation made in Birth Record. (Exempt
from destruction request requirement)
2400-07 Reports of Death - Reports of death filed by funeral
directors or persons acting as such. RETENTION: Until receipt of
death certificate. (Exempt from destruction request requirement)
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Part 5: County Indigent Health Care Program
Records
4825-01 Accounting Records - Records, vouchers, and procedures
that establish a clear, accurate audit trail of each expenditure.
RETENTION: FE + 3 years. [By regulation - 25 TAC 14.1(f)(1)(I).]
Retention Note: FE is the state fiscal year ending August
31.
4825-02 Case Records
a) Denied applicant - Application, written statement of truth
of information signed by applicant, eligibility worksheet, assistance
form, written notice of eligibility decision, reason for denial,
and explanation of the county's appeal process. RETENTION: FE
+ 3 years. [By regulation - 25 TAC 14.1(c)(11).]
Retention Note: FE is the state fiscal year ending August
31.
b) Eligible applicant - Application, documentation and verification
of eligibility, monthly financial and activity reports, and eligibility
reviews. RETENTION: 3 years past the last date on which service
was given.
4825-03 State Legalization Impact Assistance Grant Records
(SLIAG)
a) Accounting records - Financial and supporting documents, statistical
records, and any other records pertinent to the services for which
a claim or cost report was submitted. RETENTION: 3 years and 90
days after the end of the contract period or for 3 years after
the end of the federal fiscal year in which services were provided,
if a provider agreement/contract has no specific termination date
in effect. [By regulation - 40 TAC 63.13(a) and 69.205(b).]
Retention Notes: a) The contract period means the beginning
date through the ending date specified in the original agreement/contract;
extensions are considered separate contract periods.
b) If any litigation, claim or audit involving these records
begins before the three-year period expires, the provider must
keep the records and documents for not less than three years
and 90 days or until all litigation, claims, or audit findings
are resolved.
c) The case is considered resolved when a final order is issued
in litigation, or the Department of Human Services and the contractor
enter into a written agreement.
d) Records of non-expendable property acquired under the contract
must be maintained for three years after the final disposition
of the property.
b) Medical records - Case documentation of health services provided
eligible legalized aliens. RETENTION: 5 years after medical services
end. [By regulation - 40 TAC 63.13(a) and 69.205(b).]
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Part 6: Animal Control and Health Records
Retention Note: The retention periods in this part are
applicable to the records of any animal shelter owned and/or operated
by a local government and of the local health authority designated
by a commissioners court or the governing body of a municipality
for the purposes of rabies control, pursuant to Health and Safety
Code, Section 826.017.
4850-01 Activity Reports and Logs - Daily or weekly activity
reports or logs on animal shelter or animal control operations,
including field officer reports, kennel log sheets, statistical
summaries, logs of response to animal-related incidents, etc. RETENTION:
1 year. (Exempt from destruction request requirement)
4850-02 Animal Bite Records - Records of investigation
of bites by animals, including reports or copies of reports by or
to physicians, veterinarians, health officers, animal shelter personnel,
law enforcement officers, or the Texas Department of Health; quarantine
reports relating to the observation and testing of the animal; and
similar records pertinent to the disposition of animal bite incidents.
RETENTION: 3 years; or, if the person bitten is a minor, until the
person's 20th birthday, whichever later.
4850-03 Animal Permit and License Records- Includes those
issued to pet owners, kennel or wildlife exhibit operators, and
other persons pursuant to local ordinance or order.
a) Applications for and copies of permits or licenses. RETENTION:
Expiration or revocation + 3 years for granted permits or licenses;
date of denial + 1 year for denied applications. (Denied applications
are exempt from destruction request requirement.)
b) Applications and authorizations for variances or exemptions
from animal control licensing regulations. RETENTION: Expiration
or revocation + 3 years for approved variances or exemptions;
date of denial + 1 year for denied applications. (Denied applications
are exempt from destruction request requirement.)
c) Logs or reports of permits or licenses and variances or exemptions
issued. RETENTION: 2 years.
4850-04 Animal Shelter Control Records - Records of each
animal received at an animal shelter, including data relating to
its admission and condition and its reclamation, adoption, sale,
or destruction. RETENTION: 1 year. (Exempt from destruction request
requirement)
4850-05 Citations, Notifications of Violations, and Warning
Notices - Animal control officer's copies of these instruments issued
to members of the public or businesses subject to state and local
animal control regulations, including documents verifying that the
violations have been corrected. RETENTION: Verification of correction
+ 3 years.
4850-06 Complaints - Complaints received from the public
or from other agencies regarding animal control issues, including
possible violations of animal control regulations. RETENTION: Resolution
or dismissal of the complaint + 3 years.
4850-07 Communicable Disease Reports - Copies of reports
of actual or suspected rabies, anthrax, brucellosis, or other reportable
communicable diseases of animals or humans submitted by veterinarians
or other personnel employed by an animal shelter to a local health
authority. RETENTION: 3 years.
Retention Note: A communicable disease report, except
one associated with an animal bite case as described in item number
4850-02, need be retained among the records of an animal shelter
only as long as administratively valuable if the health authority
to which the report is submitted is part of the same government
that operates the shelter.
4850-08 Controlled Substance and Dangerous Drug Records
a) Veterinary controlled substances logs and inventories. RETENTION:
2 years. [By regulation and by law - 21 CFR 1304.04(a); Health
and Safety Code, Section 481.067; 37 TAC 13.61(a).]
b) Record of each acquisition and each disposal of a dangerous
drug. RETENTION: 2 years from date of acquisition or disposal.
[By law - Health and Safety Code, Section 483.024.]
c) Copy 3 of triplicate prescription form used to prescribe
a controlled substance. RETENTION: 2 years. [By law - Health and
Safety Code, Section 481.075(d)(3).]
4850-09 Lost Animals, Reports of - Logs, registers, or
reports of lost, strayed, or stolen animals. RETENTION: 1 year.
(Exempt from destruction request requirement)
4850-10 Rabies Vaccination Certificates - Copies of certificates
of rabies vaccinations performed by veterinarians. RETENTION: Date
of issuance + 3 years. [By regulation - 25 TAC 169.29(c).]
4850-11 Shelter and Quarantine Facility Inspection Reports
a) Annual inspection reports of publicly-owned animal shelters
by a licensed veterinarian as required by Health and Safety Code,
Section 823.003(d) in counties with a population of 75,000 or
more, or any similar annual inspection reports of such shelters
as may be required by municipal or county regulation. RETENTION:
3 years.
b) Annual or other periodic inspection reports by personnel
of the Texas Department of Health of a shelter as an animal quarantine
facility, including any documentation relating to the correction
of deficiencies or to an appeal of report findings. RETENTION:
3 years.
4850-12 Sterilization Documentation - Sterilization agreements,
veterinary reports that sterilization would jeopardize animal's
life, confirmation of sterilization, letters stating animal has
died or been lost or stolen before sterilization, notices of failure
to receive letters of confirmation, and records of reclamation from
owners. RETENTION: 1 year. (Exempt from destruction request requirement)
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Part 7: Records of the County Inspector of
Hides and Animals
Retention Note: The office of county inspector of hides
and animals is authorized to be filled by election in only a few
Texas counties, and in some of those the position has been deliberately
left vacant. The retention periods in this part are also binding
on the county clerk or any other current custodian of the records
of a defunct office of the inspector of hides and animals. This
part should also be used in determining the disposition of any
extant records of the office of the county inspector of sheep,
which was abolished in 1915.
4875-01 Auction Record - Record and account of proceeds
from the sale at public auction of hides and animals seized and
condemned by court order. RETENTION: 1 year after deposit of sale
funds. (Exempt from destruction request requirement)
4875-02 Expense and Collections Reports - Annual, monthly,
or other periodic reports to the commissioners court or the county
auditor of office expenses incurred or of fines, costs, judgments,
claims, and commissions collected for the county. RETENTION: AV.
(Exempt from destruction request requirement)
4875-03 Fee Book - Account of fees received for the inspection
of hides and animals and for the authentication and acknowledgment
of bills of sale. RETENTION: FE + 5 years.
4875-04 Inspection Record - Record of inspection of each
animal or hide sold in the county, leaving the county for sale or
shipment, driven in the county for slaughter, slaughtered, or for
other reasons as provided by law. RETENTION: 3 years. (Review before
disposal; some records of this type may merit permanent retention
for historical reasons.)
4875-05 Marks and Brands Records - Certified copies provided
by the county clerk of recorded marks and brands in the county and
persons authorized to gather, drive, or handle stock bearing each
brand or mark, including subsequent notations of the sale of animals
bearing the recorded brands. RETENTION: PERMANENT.
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