CMS Pub. 100-04, ch. 1, § 110.3

The hospital must maintain a medical record for each inpatient and outpatient. Medical

records must be accurately written, promptly completed, properly filed and retained, and

accessible. The provider must use a system of author identification and record

maintenance that ensures the integrity of the authentication and protects the security of all

record entries.

The provider (hospital, skilled nursing facility, and home health agency) must retain

medical records in their original or legally reproduced form for a period of at least five

years after it files with its FI the cost report to which the records apply, unless State law

stipulates a longer period of time.

After payment of the bill, the provider need not retain administrative and billing work

records provided that, and only to the extent that, such material does not represent critical

detail in support of summaries related to the records outlined in §110.2. These records

include punch cards, adding machine tapes, internal controls, or other similar material not

required for record retention.

Providers must retain clinical records as follows:

• The period of time required by State law;

• Five years from the date of discharge when there is no requirement in State law;

or

• For a minor, three years after a resident reaches legal age under State law.