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US · guidance

CMS SOM App. A, Tag A-0439

§482.24(b)(1) - Medical records must be retained in their original or legally reproduced

activein force · 2026-07-22 – presentas-observed

form for a period of at least 5 years.

Interpretive Guidelines §482.24(b)(1)

Medical records are retained in their original or legally reproduced form in hard copy, microfilm,

computer memory, or other electronic storage media. The hospital must be able to promptly

retrieve the complete medical record of every individual evaluated or treated in any part or

location of the hospital within the last 5 years.

In accordance with Federal and State law and regulations, certain medical records may have

retention requirements that exceed 5 years (for example: FDA, OSHA, EPA).

Survey Procedures §482.24(b)(1)

• Determine that records are retained for at least 5 years, or more if required by State or

local laws.

• Select a sample of patients, both inpatient and outpatient who were patients of the

hospital between the previous 48-60 months. Request their medical record. Is it

promptly retrieved? Is it complete? Is it in original or in a legally reproduced form?

History

Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08

Provenance

Source
cms.gov
Retrieved
2026-07-22
Edition
som-2026-07-22
Content hash
f5e2537ab7809d4b54a0d14939f457d4f09d1880f6c3af2fa72651dea98ec340
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