MEDICAL RECORDS 35-02-009

PURGING ACTIVE MEDICAL RECORDS

POLICY STATEMENT.
The Division of Veterans Healthcare Services (DVHS) requires each of the New Jersey Veterans
Memorial Homes (VMH) to practice purging the Medical Records of residing residents to
reduce the number of inactive pages in a residents Medical Record, in accordance with the New
Jersey State Department of Health and Senior Services and the U.S. Department of Veterans
Administration regulatory requirements.
PURPOSE.
This policy and procedure serves to ensure that each of the New Jersey Veterans Memorial
Homes implements a process that periodically removes inactive pages of the Medical Record,
reducing the number of inactive pages in the residents Medical Record that is kept at the nursing
station.
DEFINITIONS.
Purging - the removal from a Medical Record of pages that are no longer actively needed by
staff in
providing care to residents.
Interdisciplinary Team (IDT) - a group of staff members, both professional and ancillary,
representative of each service, coordinated by a Registered Nurse (RN), and responsible for the
development of individual resident care and treatment plans, in accordance with the New Jersey
Department of Health and Senior Services licensing standards.
PROCEDURE.
A. The following list of forms may be deleted from active charts after the amount of time
specified next to each item. Individual charts are labeled indicating the name of the
resident, the date pages were deleted from the chart, and the signature and title of the
person who purged the record.
History and Physical: Admission H&P, and the results of the most recent
examination must remain in the chart.
Medical Plan of Care and Initial certification and medical plan of care, and
re-certification
Recertification: for the last six (6) months must remain in the chart.
Physicians' Orders: Admission orders and all orders for the last six (6)
months must remain in the chart.
Physician Progress Notes: Admission note and all notes for the last six (6)
months must remain in the chart.
Dietary: Initial assessment and all notes for the last six (6)
months must remain in the chart.
Activities: Initial evaluation and all notes for the last six (6)
months must remain in the chart.
Nurses Notes: Initial note and all notes for the last three (3)
months must remain in the chart.
Medication and Treatment: Initial records and records of all medication and
treatment sheets. Treatments that have been provided during the last six (6) months must
remain in the chart.
Laboratory, Radiological and Records of all laboratory, radiological and other
diagnostic
Diagnostic Tests: tests for the last six (6) months must remain in the
chart.
Rehabilitation: Initial evaluation and all notes for the last six (6)
months must remain in the chart.
Social Services: Initial evaluation and all notes for the last six (6)
months must remain in the chart.
Transfer Forms: Records of all transfers to and from the facility that
occurred in the last six (6) months must remain in the chart.
B. The Medical Record shall be thinned to provide for ease of use by the Interdisciplinary
Team members by transferring original records into a secondary record know as an
Overflow Record or Overflow File. This will be accomplished while continuing to
protect the medical record against loss, destruction, or unauthorized use.
a. Each Veterans Memorial Home shall establish a monthly Thinning/Purging
Schedule guiding how the Medical Record (Chart) will be thinned.
b. The monthly thinning and maintenance of each Medical Record on the resident
living units will be completed according to the established schedule. Any
required maintenance will be completed (papers reinforced, placed in plastic, etc.)
when records are purged. All stickers (DNR, DNH, Falls Precautions, etc.) will
also be verified, as necessary.
c. Any paperwork removed from the Medical Record will be inventoried (the name
of the form and the time frame which the thinned paperwork reflects) on the
Medical Record Thinning Checklist, secured, and placed in the Overflow Record /
Overflow File.
d. The current month is not included in the specified time-frame when thinning the
Medical Record. For example, the retention time for Physicians Orders is six
months and the current date is September 10, 2006. Since the current month is
not a complete month, the six months of orders that must remain in the Medical
Record include August, July, June, May, April and March.
e. The paperwork thinned or purged from the Medical Record will immediately be
filed into the Overflow Record/ Overflow File. The most recent information
thinned will be placed in the front of the Overflow Record/ Overflow File.
Revised: July 2007
Revised: April 2010