Record Keeping - Patients with Antibodies

[DAWNA1983]

We are having a discussion about record keeping for folks with antibodies, transfusion reactions, etc.  If the patient is DECEASED, do we have to keep the records indefinitely?  I say TRASH them.

 

Thanks,

Dawn Arnett

[Malcolm Needs ☆]

It depends where you are working.

 

In the UK, we have to keep all records for 30 years, even if the patient is deceased.

[tcoyle]

AABB = 10 years per the 29th edition of standards.  Locally you might (and probably should) have a policy for record retention.

[tbostock]

Yup, 10 years.

[goodchild]

I'm posing this question because I've seen a lot of variability from the BBT folks.

 

Does this mean your completed worksheets/antigrams/pathologist or reference laboratory consultations/etc documentation needs to be maintained (as some institutions interpret the standard), or are the reported results/interpretation in the LIS sufficient to meet the antibody ID/transfusion reaction retention standard?

 

We have several sets of file cabinets and have been retaining files indefinitely. Living/deceased patients are separated.

[SMILLER]

If I am not mistaken, primary records must be kept.  If a worksheet is used first when testing and results later entered into to a computer, you must retain that primary record (or scan it into something).

 

Scott

[DebbieL]

The way I read the standard, we need to keep records of certain problems indefinitely. To my way of thinking, these records of problems are kept indefinitely in the computer system and are easily accessible. We bring that patient up in the computer and we know instantly that there is an antibody problem or special requirements.

 

The CAP Standards say to keep the immediate evaluation/interpetation of a transfusion reaction for 10 years but keep the transfusion reaction problem indefinitely. Keep the paper 10 years, keep the problem forever.

 

To be on the safe side, we keep the paper panel sheets for 10 years because most other patient records are kept for 10 years. If an inspector want to see a panel sheet from 9 years ago, I will be able to produce. Because of the amount of paper, some are stored off-site in some vast warehouse never to be seen again. I will discard the paper at the beginning of the 11th year.

 

I don't know if this is right but I am sticking with it until told otherwise.

[goodchild]

I just had a discussion with the checklist interpretation group at CAP and this was one the topics I brought up.

I just received an e-mail with the interpretation from their blood bank specialists:

 

" ... about keeping of records for deceased patients, and the consensus is that indefinitely means indefinitely. However, you can scan them in and keep digital copies. You do not need to keep the paper forms. "

 

I'm also confused why my 29th edition of the AABB Standards is different, because mine doesn't say 10 years it says indefinitely on page 74.

Edited August 14, 2015 by goodchild