All clinics have to deal with the challenge of medical record retention, or keeping complete records of all their patients for a certain period of time. The biggest issue with determining the exact medical record retention period of a clinic is that there is no consistent singular law that establishes this length for every case. Practices and clinics are required to piece together various case laws, regulations, statutes, and position statements from the State Medical Board. The second biggest issue, of course, is the actual process of recording and safely storing medical records for several years.
But what is the general medical record retention period that practices can start with when determining how long to keep their records? In the US, HIPAA or the Health Insurance Portability and Accountability Act determined that all healthcare providers must retain medical records for up to six years, with the period beginning when the record was last used. In the UK, medical records must be retained for up to 20 years after the practice’s last patient interaction. With such a long retention schedule, practices have to truly consider the best way to record and store their medical records.
How Long Should Medical Records Be Kept?
There are various factors that affect the retention period for a practice’s patient medical records. While there is a general law in both the US and the UK, there are other factors that must be considered. These general laws are:
- HIPAA (US): HIPAA retention requirements state that any Covered Entity must keep their medical records for up to six years, with the time period beginning from when the paper record was last used.
- Records Management Code (UK): In the UK, the Records Management Code of Practice for Health and Social Care 2016 states that any individual or physician practice working with or alongside the NHS must keep medical records 20 years after the last patient interaction or patient’s discharge, 8 years after the patient’s death, or 25 years after the birth of the patient’s last child.
But what other factors are involved in determining how long a practice must keep their medical records? The US has several other possible parameters that must be considered:
- Insurance: Certain third-party insurance companies can impose contractual medical record retention requirements on clinics for a specific time
- State laws: Different US states have different medical retention regulations, and physicians who work across state lines will have to juggle these different state regulations
- Statute of Limitations: The Statute of Limitations gives patients a final date for possibly filing a lawsuit against a practice or physician, and it is required by the practice to retain patient records until the Statute of Limitations has passed. For example, if a patient is treated by a physician until they are 22, and if the state’s malpractice action period is up to 7 years, the physician will need to retain the patient’s records until they are 29. Keeping these records is essential to defend the practice orp physician from any malpractice allegation
- Visit frequency: Patients who visit doctors less frequently may have a longer medical retention period than patients who visit more frequently
How to Create The Optimal Medical Record Retention Policy
Complying with medical record retention regulations and laws is crucial for any practice to avoid any possible consequences, such as increased legal liability and fines. By working with your team to create the optimal medical record retention times policy, you can reduce the chances for issues such as non-compliance, while making medical records more accessible for anyone who might need them -- patients, law firms, auditors, payers, and all other relevant entities.
Here are some reminders while working on your retention policy:
- Determine the exact period your practice is required to retain patient records. The standard that most US practices follow is HIPAA’s six-year medical record retention requirement, but it’s important to know if there are any specifics that apply to your area or certain types of clinical records. Check the requirements of any accrediting agencies that work with your organization, or any local state requirements with stricter regulations than HIPAA. For example, health care providers managed by Medicare must retain their medical records for up to ten years. Check the retention recommendation of the American Health Information Management Association, or AHIMA.
- Record whatever medical patient’s record retention policy and medical record archiving policy you come up with. It’s important that your clinic or healthcare provider facility has clear documentation of your exact policies for patient medical record retention and medical record archiving, as there will be times when the primary staff members are unavailable. This documentation should include information on which medical records and billing records are retained, as well as how they should be retained. There are sample records retention and management policies available online.
- Go through all possible options for medical health record retention. Many health organizations are now choosing electronic archives of their medical records, by either scanning images and discrete health data records of their adult patient records, or using their preferred EMR or EHR tool. It’s important that you and your team consider all possible retention options, such as:
- Converting the data in your system into electronic records
- Maintaining a legacy system in your records
- Scanning and printing the records, which can be time-consuming, labor-intensive, and prone to human error
- Migrating, storing, and recording data elements in an electronic archive, which is becoming the most popular option because of the ease of hospital record retrieval as well as the long-term ROI
- Review your policy with your legal counsel before putting it into effect. There are countless variables that must be considered when drafting your medical record retention policy, so it’s essential to get outside legal counsel help to ensure that your policy is foolproof. Attorneys can help validate state and federal laws, and the policies of any relevant agencies, state associations, and medical boards. They can also assist you with policies on record destruction.
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