Medical Records

Q: Do medical records in an off-site, business occupancy building have to be fire protected? This was not cited during our survey, but I heard from another hospital that this was cited at their clinics. Our clinics are not protected with automatic sprinklers since it is not a requirement for business occupancies.

A: Many accreditation organizations have specific standards that require the medical records to be protected from fire. This is based on the CMS Condition of Participation standard §482.24(b) which says in the Interpretive Guideline section: “Medical records must be properly stored in secure locations where they are protected from fire, water damage and other threats.” This may be accomplished in various methods, such as placing the medical records in vaults, fire-rated cabinets, or in a room that is fire-rated. Fire protection may be installed in the form of sprinklers or clean agent suppression systems. Please note that the presence of sprinklers and associated piping does not constitute a threat from water damage. The Life Safety Code says hazardous areas in business occupancies include areas used for general storage, which would apply to the storage areas for medical records. Therefore, if the medical records are not stored in a fire-rated cabinet, then you would have to do one of the following:

  1. Enclose the area with 1-hour fire resistive construction, or;
  2. Protect the area with automatic sprinklers.

You indicated that these areas are not protected with automatic sprinklers, so it appears to me that you would have to enclose the medical record storage area with 1-hour fire resistive construction, or install fire-rated cabinets.