AGENCY: Department of Health and Human Services. Division of Substance Use and Mental Health. State Hospital
SERIES: 8642
TITLE: Patient case records
DATES: 1885-
ARRANGEMENT: Numerical by patient identification number.
DESCRIPTION: These records provide complete documentation of the diagnosis and treatment of individuals confined to the Utah State Hospital. Information includes treatment plans; physical and psychological examinations; discharge summaries; psychiatric, social history, nursing, nutritional and recreational assessments; vocational rehabilitation assessments; dental examinations, etc. May also contain legal commitment papers, court orders and neurological consultations. When retention is completed certain records (see records series 25023) are scanned and maintained permanently. Documentation relating to client or patient medical information. Includes physical, psychiatric, dental, pharmaceutical, medical history, treatments, notes, reports, forms, memorandums, examinations, physical therapy, assessments, and all other related materials.
RETENTION
Permanent. Retain for 85 year(s)
DISPOSITION
Transfer to Archives.
RETENTION AND DISPOSITION AUTHORIZATION
Retention and disposition for this series were specifically approved by the State Records Committee.
APPROVED: 12/1992
FORMAT MANAGEMENT
Paper: Retain in Office for 10 years after adult patient is discharged or until discharged juvenile reaches 18 plus 4 years and then transfer to State Records Center. Retain in State Records Center for 75 years and then transfer to State Archives.
Microfilm master: For records prior to and including 1995. Retain in State Archives permanently.
Microfilm duplicate: Retain in Office until records have met retention and then transfer to State Archives.
Computer data files: Retain in Office permanently.
APPRAISAL
Administrative Historical
This disposition is based upon Utah Administrative Code R432-100-34. Medical Records (4)(b-d) (2017), which states, "(b) Records of discharged patients shall be collected, assembled, reviewed for completeness, and authenticated within 30 days of the patient's discharge. (c) Medical records shall be retained for at least seven years. Medical records of minors shall be kept until the age of eighteen plus four years, but in no case less than seven years. (d) The Hospital may destroy medical records after retaining them for the minimum time period. Prior to destroying medical records, the hospital must notify the public by publishing a notice in a newspaper of statewide distribution a minimum of once a week for three consecutive weeks to allow a former patient to access the patient's records. (e) The hospital shall permanently retain a master patient/person index that shall include: (i) the patient name; (ii) the medical record number; (iii) the date of birth; (iv) the admission and discharge dates; and (v) the name of each attending physician."
PRIMARY DESIGNATION
Exempt. Utah Code 63G-2-107(1)(b) (2016); 45 CFR 160 & 164 (2008).
SECONDARY DESIGNATION
Controlled. Utah Code 63G-2-304 (2008). Medical, psychiatric and psychological data.
Private. Utah Code 63G-2-302(1)(b) and (2)(d) (2019).
Public