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How Long Must Patient Records Be Kept?

Question: A significant amount of my office storage space is devoted to patient records. I am currently maintaining a large number of patient records for patients that I have not examined or treated for many years. I am considering discarding some of the old patient records. How long am I required to maintain a patient record before it can be discarded?

Answer: Florida optometrists have an absolute duty to keep written records documenting the examinations, treatments, and prescriptions rendered to their patients. In addition to examination and treatment results, the "patient record" is required to contain the name and signature of the optometrist who examined and/or treated the patient on each separate occasion. An optometrist is obligated to maintain full and independent responsibility and control over all his/her patient records.

The Florida Board of Optometry has specifically addressed the length of time patient records must be maintained. The Board adopted Rule 64B13-3.003, Florida Administrative Code, governing several issues involved in patient records. Section (5) of Rule 64B13-3.003 expressly addresses the minimum length of time that a patient record must be maintained by the optometrist. The Rule requires that the optometrist keep patient records for a period of at least 5 years after the last entry in the record. Consequently, an optometrist would be authorized to discard only those patient records that have no entries in them during the 5 year period immediately preceding the anticipated date of discard.

Section (5) of Rule 64B13-3.003 also addresses the issue of the handling of patient records that are less than 5 years old upon the discontinuance of the optometrist’s practice. Upon the discontinuance of his or her optometric practice, the optometrist has several options for maintaining patient records that are less than 5 years old. The optometrist has the option to transfer patient records that are less than 5 years old to another Florida licensed optometrist or to an eye care practitioner licensed under Chapter 458 or 459, Florida Statutes (medical or osteopathic doctor practicing ophthalmology) where they may be obtained by the patient. Alternatively, the optometrist can keep the patient record in his or her possession until at least 5 years have passed since the last entry during which time the patient records shall be made available to the patient. Section (6) of Rule 64B13-3.003 describes the manner in which an optometrist who is discontinuing his or her practice shall provide notice to patients of the location that the patient record may be obtained.

Some optometrists choose to retain patient records for periods in excess of 5 years from the date of last entry. Their motivations for keeping patient records beyond the minimum 5 year period mandated by Rule 64B13-3.003 include not wanting to discard any patient record prior to the expiration of the potential 7 year statute of limitation for medical malpractice actions contained in subsection 95.11 (4)(b), Florida Statutes.