AGENCY: Department of Health and Human Services. Division of Services for People with Disabilities. Developmental Center

SERIES: 28194
TITLE: Patient medical progress notes
DATES: 1930-2015.
ARRANGEMENT: Numerical by date

DESCRIPTION: These records are created when an individual is seen by a physician or specialist for healthcare matters.

These records are used to document each individual's symptoms, the type of clinic, procedures performed, and physician's orders (including communication to other medical staff). Medical staff review and sign off on notes at end of notation. Records include individual's name, file number, name of clinic, name of physician or specialist, presenting problem, medication changes, orders, follow-up and return to clinic (if applicable).

RETENTION

DISPOSITION

RETENTION AND DISPOSITION AUTHORIZATION

Retention and disposition for this series were specifically approved by the State Records Committee.

APPROVED: 02/2013

FORMAT MANAGEMENT

Paper: Retain in Office for 10 years and then destroy.

APPRAISAL

Administrative

PRIMARY DESIGNATION

Private. 63G-2-302(1)(6)

SECONDARY DESIGNATION

Controlled. 63G-2-303

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