AGENCY: Department of Health and Human Services. Office of Children with Special Healthcare Needs

SERIES: 1789
TITLE: Patient's medical case files
DATES: i 1946-

DESCRIPTION: This is a complete record of the medical treatment given to handicapped children by the bureau. It includes Closure/Reopen Forms, Unit Scheduling Record, Diagnosis Listing, Appointment Record, Progress Notes, Clinic Physician's Recommendations, Social Worker's Notes, Growth Charts, Reports of Medical Examinations, Examination, X-Ray, and Laboratory Reports, Parents' Questionnaire, Physician Selection, Correspondence, Log Sheets, Report of Psychological Examination, Developmental Tests, Certification of Handicapping Conditions, Request for Information, Release of Information, Hospital Treatment Summary, Nutritional Problems and Recommendations, and Release of Information Forms. Information includes age, appearance, assets and debts, brothers and sisters, condition of living quarters, current and past addresses, date of birth, educational level, employer, ethnic group, expenditures, family history, food purchase and consumption, income, marital status, medical information, name, name of kin, number of children, occupation, parent's birth information, personality inventory, physical characteristics, physical disabilities, psychiatric information, race, salary, sex, signature, social security number, telephone number, and insurance coverage. Note that some of this information is collected about the patient's parent(s). The file also contains a record of treatment, signed consent for treatment forms, signed consent to release information forms, and information on the patient's health care provider.


Retain for 78 year(s)




Retention and disposition for this series were specifically approved by the State Records Committee.

APPROVED: 08/1986


Paper: Retain in Office for 1 year and then transfer to State Records Center. Retain in State Records Center for 77 years and then destroy.



The retention period for these records are dictated by the fact that they are the medical records of handicapped children. Many of these children have recurring problems and files that are closed can be reopened again at any time. Due to that fact, the files cannot be microfilmed until the child reaches majority which in Utah is 18 years of age (UCA 15-2-1). At 18, he/she is no longer eligible for services from this bureau. Then the chart could be microfilmed. The record is maintained should the individual apply for disability. A 75 year retention is consistent with workmen's compensation claim files.