AGENCY: Lehi (Utah)
SERIES: 14175
TITLE: Patient case files
DATES: 1953-1968.
ARRANGEMENT: Alphabetical by patient's surname.
DESCRIPTION: The patient case files were created by the various medical personnel that had contact with the patient: doctors, nurses, pathologists, and sometimes medical insurance personnel. They are the cumulative history of a given patient's stay in the hospital.__For many patients there is more than one case file, indicating that a new file was created every time the patient sought medical care from the system.
The case files may include any of the following types of documents: admission and discharge records, condition of admission forms, lab reports, medication records, charts, medical histories, anesthesia records, nurses reports, prescription forms, consent forms, EKG graphs, and summary indexes to the case file, The nurses' reports are the most informative in that they give an hourly update on the patient's status and other data concerning the patient's comments, state of mind, and visitors.
RETENTION
Permanent. Retain for 100 year(s)
DISPOSITION
Transfer to Archives.
RETENTION AND DISPOSITION AUTHORIZATION
These records are in Archives' permanent custody.
FORMAT MANAGEMENT
Paper: Retain in State Records Center for 100 years and then transfer to State Archives with authority to weed.
APPRAISAL
Historical
These case files would not normally have permanent retention, but are being preserved as a representative sample.
PRIMARY DESIGNATION
Private. Access limited to patient/doctor for 100 years (children), 75 years (adults) under GRAMA. May be permanently restricted under federal HIPAA.
SECONDARY DESIGNATION
Controlled