On many occasions when handling medical malpractice cases, attorneys will face the question of how long a medical institution must preserve slides, specimens, tissues or biopsies.
The state of Illinois has what is referred to as the CLIA laboratory certification program. This is part of the code of federal regulations CFR 42 Part 430 that refers to federally required record retention time limits. Most medical providers in the state of Illinois use the CLIA requirements in determining the retention time for laboratory or surgical specimens.
The amount of time that a hospital is required to retain bits or pieces of their patients depends on the kind of the bits and pieces.
• Test requisitions and authorizations, including the patient’s chart or medical record if used as the test requisition or authorization, must be retained for two years.
• Test procedures, proficient testing records and laboratory quality system assessments all must be kept for two years.
• Most pathology and immunology test reports have to be kept for ten years.
• Cytology slides are required to be kept for five years and histopathology slides are required to be kept for ten years. There are no other requirements for other kinds of slides.
• Pathology specimen blocks must be retained for two years but tissue remnants need only be retained if they are pathology remnants until there is a completion of diagnosis.
Keep in mind that there is a trend in the medical community to subcontract laboratory or pathology services to independent contractors. The obligation of the medical provider to retain materials, while it can be contracted out, usually does not absolve the medical provider of the ultimate responsibility of making sure the records, slides and tissues are retained for the required statutory period.
In summary, depending on the type of test procedure, test record, slide, specimen, or tissue, the medical institution may be required to retain it for a minimum amount of time.. Their failure to retain it for the required period of time can result in either a claim of spoliation or other discovery issues and rights that may be important in a medical malpractice case.