Record retention made easy
Nothing raises more questions when closing a practice than what to do with the medical records. It is important to remember that the physical record (whether paper or electronic) is the property of the practice while the information in the record is the property of the patient. Thus the patient is entitled to obtain copies of the record, but the physician must retain the original in case a liability claim is filed.
- Retention rules vary by state. Contact state governments and/or a liability insurer for guidance, including the legal length of time records should be retained, and any other state-specific requirements. State medical societies may also have information.
- If no state-specific requirements exist, it usually is sufficient to keep original records until the statute of limitations expires or for 10 years from the date of the last visit. The records of a minor must be kept until the patient reaches the age of majority plus the time period for the statute of limitations. For example, if the age of majority is 18, the patient was 13 at date of last visit and the statute of limitations is 10 years, then the records must be kept for 5+10=15 years.
- Obtain written authorizations to transfer all patient records, particularly and specifically for sensitive information. Keep a copy of this authorization in the original record.
- When transferring medical record information, physicians may charge the patient a reasonable fee to reflect the cost of the materials used, the time required to prepare the material and the direct cost of sending the material. (Note: This fee may be determined by state law.) Physicians may make reasonable attempts to collect the fee in advance. Nonpayment or any outstanding balance, however, is not a reason to withhold records.
- Records must be stored in a place where they are safe from tampering, loss, fire, flood or unauthorized access. Some states allow transfer to microfiche or a read-only CD-ROM.
Other records, such as tax returns, bank statements, personnel files, explanations of benefits, and other financial records, also need to be retained.
- Keep tax returns, personnel files, accounts payable invoices, contracts and other financial records according to guidelines (usually seven years, but some states vary).
- Retain HIPAA documentation, such as acknowledgement of privacy notice, requests for amendments, and workforce training documentation, for six years.
- If using a professional service to destroy records, obtain certificates of destruction. Destruction can be by incineration, shredding, pulverization, or, in the case of computer media, reformatting or de-magnetization.
ACP Internist Weekly
From the November 18, 2014 edition
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- Communication scores vary significantly within practices, especially low-performing ones
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