Patient records are documents that contain important information about a patient's medical history, diagnosis, treatment, and progress. These records are crucial for providing quality healthcare and ensuring patient safety. However, what are the legal requirements for retaining patient records and how long should they be kept?
In this article, we will explore these questions and more.
The length of time records must be retained after a patient is discharged from care varies depending on federal and state laws. However, there are some recommended retention periods for different types of patient records.
While there are no HIPAA requirements for retaining medical records, the legislation does lay out policies for how long other records associated with HIPAA should be retained. HIPAA states that Covered Entities and Business Associates must record any policies, procedures, actions, or assessments carried out to comply with HIPAA policies.
The HIPAA subsection 45 CFR §164.316(b)(2)(i) says that such records must be kept for a minimum of six years after their creation or if the document outlined a policy, 6 years from when the policy was last implemented. Thus, if a policy was in place 4 years before it was either dropped or altered, the original documentation must be kept for at least 10 years from its creation date.
State laws may have longer retention requirements, so it's essential to review the specific laws in your state.
|Type of Patient Record
|Minimum Recommended Retention Period
|At least ten years after the last patient encounter
|Diagnostic Tests and Imaging
|At least five years after the last patient encounter
|Treatment Plans and Progress Notes
|At least ten years after the last patient encounter
|Billing and Insurance Records
|At least seven years after the last patient encounter
Hospitals have their own policies on record retention which may vary depending on the type of record and where the hospital is located. In general, hospitals are required to retain patient records for a minimum of seven years from the date of creation or the date when the record was last in effect. However, some states require hospitals to retain records for a more extended period.
Factors that may affect hospital record retention include:
In these cases, hospitals may need to retain records for a more extended period than the legal requirement.
EMRs are becoming increasingly popular due to their efficiency and convenience. Thus, it is worth taking note of how long they should also be retained.
EMRs are subject to the same legal requirements as paper records. Healthcare providers must ensure that EMRs are accurate, complete, and accessible. They must also retain EMRs for the same length of time as paper records.
The recommended retention periods for electronic records are the same as for paper records. Healthcare providers should ensure that their EMRs are backed up regularly and stored in a secure location to prevent loss or damage.
Physicians must maintain patient records for a minimum of six years from the last date of service, according to federal law. However, state laws may have longer retention requirements, so it's essential to review the specific laws in your state.
Failing to retain patient records can lead to legal and financial consequences, such as malpractice claims and fines.
Patients have the right to access their medical records under federal law. Healthcare providers must provide patients with their records within 30 days of the request. Some states have shorter time frames so it's essential to review the specific laws in your state.
Patients may request their records in writing or electronically, and healthcare providers must provide them in the format requested, if possible.
Electronic health record (EHR) clinics must comply with federal and state laws regarding record storage, including ensuring that records are accurate, complete, and accessible. They must also retain records for the same length of time as paper records.
New healthcare offices may be required to retain old patient records for seven years to ensure compliance with federal and state laws regarding record retention. This includes medical histories, diagnostic tests, treatment plans, progress notes, and billing and insurance records.
In addition to the legal requirements for retaining patient records, there are other areas related to record retention that healthcare providers should be aware of. These include:
|Mental Health Records
|Some states require mental health records to be retained for a longer period of time than general medical records and require written consent from the patient or their legal representative before disclosing mental health records.
|Deceased Patient Records
|Some state laws require healthcare providers to retain deceased patient records for a certain period of time, to ensure that the records are available for any future legal claims or to provide information to family members or other authorized individuals who may need access to the records.
|Record Retention for Minors
|Healthcare providers must retain minor medical records for a certain number of years after the patient reaches the age of majority (usually 18 years old).
|Record Retention for Clinical Trials
|Federal regulations require clinical trial records to be retained for at least two years after the last marketing application is approved for the drug or device used in the trial. Some states may have additional retention requirements for clinical trial records.
|Record Retention for Research Purposes
|Federal regulations require research records to be retained for at least three years after the completion of the research. It is important for healthcare providers involved in research to review the specific laws in their state to ensure compliance.
Patient record retention is an important aspect of providing quality healthcare and ensuring patient safety. Healthcare providers must comply with federal and state laws in terms of record retention and provide patients with access to their records.
By understanding the legal requirements and recommended retention periods for different types of patient records, healthcare providers can ensure compliance and avoid legal and financial consequences.