VETERANS' CORNER: History of health record retentions
• EDITOR’S NOTE: Veterans’ Corner, a column to inform armed-forces veterans about services and benefits available to them, appears the first Sunday of each month.
The VA’s past and current requirements for health record retention and destruction are described below. The retention and destruction requirements pertain to all veterans’ health records, whether paper or electronic.
From the inception of the Veterans Health Administration health record to 1955, all records were retained.
In 1955, all inactive health records were transferred to the National Archives and Record Service.
In 1965, the record retention period was changed to 15 years after date of last visit.
Records of all veterans who had not received care since 1950 were destroyed in 1965.
In 1965, the “perpetual record” was created. The perpetual record included four types of documentation: the application for medical benefits, the hospital summary, the operation report and the tissue examination report.
From 1965 to 1979, the perpetual record was maintained from five years after last date of care. The rest of the health record that was not considered part of the perpetual record was maintained for 15 years after date of last care.
A moratorium on destruction of all records was in place from 1979 to 1987.
From 1979 to present, all health records must be maintained for 75 years after date of last care.
While paper records are maintained, they are not stored at the site where care was received indefinitely. If a veteran has not received care within the last three years at a VA facility, the paper record is sent to an approved storage facility. The facility where the vet received care can request the paper records be returned to that facility at any time.
Research records are not considered part of the health record and are maintained separately. Prior to July 2008, Research Program Records were maintained for five years after completion of the research study. But since July 2008, research records are maintained indefinitely and are not destroyed.
The Department of Veterans Affairs has had automated information systems in its medical facilities since 1985, beginning with the Decentralized Hospital Computer Program (DCHP) information system, including extensive clinical and administrative capabilities. The Veterans Health Information Systems and Technology Architecture (VistA), supporting ambulatory and inpatient care, delivered significant enhancements to the original system with the release of the Computerized Patient Records System (CPRS) for clinicians in 1997. CPRS provides a single interface for heath care providers to review and update a patient’s medical record and to place orders, including medications, special procedures, X-rays, patient care nursing orders, diets and laboratory tests. VistA Imaging provides a multimedia, online patient record that integrates traditional medical chart information with medical images, including X-rays, pathology slides, video views, scanned documents, cardiology exam results, wound photos, dental images, endoscopies, etc., into the patient record. Retention for records maintained in CPRS, including VistA Imaging, is 75 years.
The Department of Veterans Affairs and the Department of Defense are currently partnering together to improve the communications between its Electronic Health Records to improve health care to our veterans.
NOTE: The records destroyed in the July 12, 1973, fire at the National Personnel Records Center in St. Louis were official military personnel files Records for Army and Air Force.
This information is from the Health Information Management Office of Informatics and Analytics Fact Sheet.
For information, call Brenda Stormer, Veterans Affairs Office, at (724) 465-3815.