Medical Records Retention: Is Your Practice Compliant?

medical records

Every healthcare practice in the United States is governed by state and federal regulations with regard to the retention of medical records. Yet, a large amount of data is generated in medical offices every day and it is not possible to retain every piece of patient information indefinitely.

Medical practices that keep paper records or are in the process of transitioning to a paperless office must invest time in converting paper records to electronic health records. That said, even digital storage of data takes up space, albeit less than physical documents. This means that practices must understand what needs to be saved for how long.

Is your practice compliant with medical records retention? Are you saving every specific type of document for the required time?

Records must be saved for at least the required legal timeframe. The retention policy for patient medical information must also specify where and how the records are saved and how they are destroyed. Here is a template your office can follow.

Department-Wise Medical Record Retention

It is important to realize that every department in a healthcare organization may need to implement its unique retention policies since they generate different types of medical records. The compliance officer at your practice should research and review the retention policy for each department at the office. These policies should be endorsed by the management before they are implemented.

Retention Period for Patient Medical Records

Medical practices are required to store and produce certain records that have evidentiary value in the event of legal proceedings. Such records need to be stored indefinitely.

Records of insurance payments and ledger entries should be stored for a minimum of 10 years. Also included in this timeframe of retention are reimbursement vouchers from Medicare, Medicaid, and other legal entities that the practice has a contact with. Correspondence and paperwork relating to billing disputes raised by patients should also be retained for a minimum of 10 years.

Records that can be destroyed after 7 years include claims, bills, and patient demographic information. Other patient activity and monthly balance reports also fall into this category. In general, this timeframe of record retention applies to documents obtained by patients from external sources and payers.

Secure Storage of Medical Records

An essential feature of the medical record retention policy at your practice should be to store records with different retention periods separately. Within the category, records should be divided and similar records stored together. For example, monthly reports and weekly reports should be subcategorized for storage. Folders should be labeled with the type of document, reporting period, and the date before which they should not be destroyed. Within each folder, reports should be categorized by date and information pertaining to individual patients should be categorized by patient name.

To maintain the integrity and security of the stored data, only authorized personnel should have access to it. The retained records that are not viewed on a daily basis should be password protected or stored under lock.

Destruction of Old Medical Records

Every medical office should conduct a six-monthly review to assess which of the retained records can safely be destroyed to free up storage space. HIPAA policies must be adhered to when destroying old medical records. The administrator of the medical practice should authorize this in compliance with various regulations.

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