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