Kingdom of Saudi Arabia
المملكة العربية السعودية
Ministry of Health
وزارة الصحة
Executive Management of
اإلدارة التنفيذية للتخطيط والتطوير
Organizational Development
إدارة الجودة وسالمة المرضى
Quality Management & Patient Safety
Administration
DPP DPP-MRD-
EFFECTIVE
POLICY TITLE DATE REVISION DATE APPLIES TO
Storage and All Medical Record
Retention of Department employees at
Medical Records King Saud Medical City.
1. PURPOSE
Have a standard storage and retention system of the medical records in order to ensure easy and
quick accessibility.
2. OPERATIONAL DEFINITION(S)
2.1 Medical Record Storage- a safe storage of records is a vital good records management to
have a system in place to determine who has the record, where they have the record and
when to return the records.
2.2 Medical Record Retention- A records whether on paper or stored in a computer, must be
retained and be retrievable for at least as long as the law requires to keep them
3. EQUIPMENT/MATERIAL/FORM(S)
3.1 Patient medical record
3.2 Storage cabin
3.3 Computer
3.4 Printer
3.5 A4 paper
4. POLICY STATEMENT and PROCEDURES
4.1 All patients’ medical records shall be retained by the Health Information Management
according to
the Ministry of Health guidelines, legal, and regulatory Requirements in a safe and hazard free
environment, with the exception of patients treated By the Emergency Department.
4.2 When a medical records is initiated, King Saud Medical City HIS system will issued a patient
number.
4.2.1 Patient Number given to the medical record for network tracking purposes
4.2.2 Serial record number used to determine how medical records are organized and stored
in the Medical Records Department
4.2.3 A serial record number contain six digits or more ( depends upon the increase of the
patient registered)
4.2.4 One patient number for one patient will be used for all hospital services (Inpatient,
Outpatient, ER, Dental and others)
4.3 A medical record is considered inactive after at least 5 years of inactivity. Any medical record
deemed inactive due to 5 years’ inactivity will be computer scan. The destructions of files is
thru shredding by the in-charge company.
4..4 Category of Medical Record-Retention period:
4.4.1 Inpatient (inactive) – 5 years
4.4.2 Outpatient (inactive) – 5 years
4.4.3 Medical Legal cases (inactive) after clearance from legal department that no legal
proceedings for files are required in future are case is closed then those files are
considering as
an inactive.
4.4.4 Electronic OPD dental (R4 system) long life
4.4.5 For minors, records shall be kept until he/she is 18 th years of age, and then for a
minimum
additional 5 years.
Policy Owner: MRD-HEALTH INFORMATION ADMINISTRATION
Page 1 of 4
Kingdom of Saudi Arabia
المملكة العربية السعودية
Ministry of Health
وزارة الصحة
Executive Management of
اإلدارة التنفيذية للتخطيط والتطوير
Organizational Development
إدارة الجودة وسالمة المرضى
Quality Management & Patient Safety
Administration
DPP DPP-MRD-
EFFECTIVE
POLICY TITLE DATE REVISION DATE APPLIES TO
Storage and All Medical Record
Retention of Department employees at
Medical Records King Saud Medical City.
4.5 Inactive medical records will be separated from active medical records, but will not be
discarded.
4.6 If there is lack of medical records storage space, electronic archiving will be utilized.
4.7 The Medical records storage area contains:
4.7.1 One hundred “100” storage cabins designed for storing active and inactive medical
records.
4.7.2 Other storage cabinet is designated for death files, extra files, Home Care Files, Protocol
files,
and Investigation files.
4.7.3 Protocol and Investigation files storage cabin is lock for confidentiality purposes
4.8`Medical records storage cabins/shelves are given a number between 00 and 99. Each medical
records storage cabin/shelves is divided into 10 sets of shelves (10 columns, 5 each back to
back) with containing 7 rows of shelves each sets. Each columns of shelves are given a number
between 0 and 9.
4.9 The last two digits of the Medical Record Number define which shelves/cabin the medical
records should be filed. While the fourth (4 th) digit defines which set of column in the
cabin/shelves the medical records should be filed in straight numerical order (e.g. the medical
order with the serial number 123456 will be filled in number four column of the 56
cabin/shelves)
4.10 In September 2006, King Saud Medical City administration decided to unify the medical
records under one numbering system.
4.11 Medical records are divided into the following categories:
4.11.1 Active medical records
4.11.2 Inactive medical records
4.11.3 Death medical records
4.12 Active medical records are record that are still under use either by inpatient wards or
outpatient
clinics. Active medical records can be either old and new:
4.12.1 As per department’s policy medical records are maintained where an information shall
be
accessible when acquired including records that are partly electronic & partly paper
based..
4.12.2 Old medical records are record that were initiated for the Riyadh Central Hospital
patients
before the KSMC.
4.12.3 City medical record unification act they are easily identified by their serial number,
which
start from 000001 to 199999
4.12.4 All the information accessible when required for record which are partly electronic
partly
manual.
4.13 In active medical records are records that have not been active for more than five years.
Active
4.13.1 The Archiving section will scan the Inactive Medical records for permanent computer
storage
4.13.2 Medical records must be registered as inactive on King Saud medical City HIS System
Policy Owner: MRD-HEALTH INFORMATION ADMINISTRATION
Page 2 of 4
Kingdom of Saudi Arabia
المملكة العربية السعودية
Ministry of Health
وزارة الصحة
Executive Management of
اإلدارة التنفيذية للتخطيط والتطوير
Organizational Development
إدارة الجودة وسالمة المرضى
Quality Management & Patient Safety
Administration
DPP DPP-MRD-
EFFECTIVE
POLICY TITLE DATE REVISION DATE APPLIES TO
Storage and All Medical Record
Retention of Department employees at
Medical Records King Saud Medical City.
before storage.
4.14 Old Maternity and Pediatric medical records are record that have been initiated by the
Maternity Hospital and the Pediatrics Hospital before King Saud Medical City medical records
unification act.
4.14.1 Old Maternity and pediatric medical records do not follow the Medical Records Dept.
rules.
4.14.2 Old maternity and Pediatric medical records are currently stored in temporary storage
cabins until they are given new Medical Records Numbers.
4.15 Inactive medical records are records that have not been active for more than five years.
4.15.1 After the scanning process if inactive medical files meeting will be held with the
Committee of medical records.
4.15.2 Discussion about the reason of destroy process will be documented in the minutes of
the meeting with the number of files that will be destroyed.
4.15.3 The Contracted private company will hold the task of destroying.
4.15.4 The destroying process of medical records will be under the supervision of a staff
member of the medical records to maintain the confidentiality of information and
completion of the destroying process.
4.16 Death medical records are records for patients who have died while receiving treatment in
King
Saud Medical City.
4.16.1 Death medical records are kept to separate cabins from other medical records for
review and study purposes.
4.16.2 Death medical records are stored on separate medical record storage cabins by the
same serial number of the file. After they have been registered as death medical
records on King Saud Medical City HIS system
5. RESPONSIBILITIES
It is the responsibility of Health Information Management and all Healthcare employees, review and monitor
the
implementation of this policy for effective compliance.
6.REFERENCES
6.1 APP-KSMC (King Saud Medical City) -022, Medical Records Completion and Maintenance
November 12, 2007
6.2 APP-NGHA (National Guard Health Affairs) -1415 -001, Medical Records Content,
Documentation and Completion.
Policy Owner: MRD-HEALTH INFORMATION ADMINISTRATION
Page 3 of 4
Kingdom of Saudi Arabia
المملكة العربية السعودية
Ministry of Health
وزارة الصحة
Executive Management of
اإلدارة التنفيذية للتخطيط والتطوير
Organizational Development
إدارة الجودة وسالمة المرضى
Quality Management & Patient Safety
Administration
DPP DPP-MRD-
EFFECTIVE
POLICY TITLE DATE REVISION DATE APPLIES TO
Storage and All Medical Record
Retention of Department employees at
Medical Records King Saud Medical City.
7. APPROVAL TABLE
8. POLICY AND PROCEDURE HISTORY
Initial PP: Version 1 DPP-MRD- 022 (V1) Dated: January 15, 2010
Replaced by: Version 2 DPP-MRD- 022 (V2) Dated: July 22,2012
Replaced by: Version 3 DPP-MRD- 022 (V3) Dated: February 18,2016
Replaced by: Version 4 Dated:
Deleted Date: ______________________________
Policy Owner: MRD-HEALTH INFORMATION ADMINISTRATION
Page 4 of 4
