Record Retention Basics for Healthcare Practices
Healthcare practices generate and maintain many different types of records, including patient health records and business records. These records help organizations maintain critical information and deliver quality services and care.
To protect records, healthcare practices should develop and implement formal record retention policies and procedures. Doing so will help establish a systematic and organized approach to record management. Further, formal policies and procedures may help defend against allegations of spoliation — i.e., that records were deliberately or maliciously destroyed.
At minimum, record retention policies and procedures should include:
- The length of time the practice will maintain records. The timeframe may depend on the type of record, state and federal laws, professional and accreditation standards, and professional liability guidance.
- A definition of which documents constitute a “legal” health record, including documentation that occurs during patient encounters as well as other types of communications, such as emails, patient portal interactions, text messages, etc.
- The form/manner in which the practice will maintain the records. For example, will records be maintained as paper documents, electronic files, or a combination of both?
- A list of records that will be maintained onsite and offsite (for example, in cloud storage or a record storage facility).
- A designated individual (role) who is responsible for policy oversight, record maintenance, and initiating the destruction of records.
- The HIPAA-compliant methods for destroying records while preserving confidentiality. The destruction method will depend on the record format and may involve shredding, incineration, physical destruction of hard drives, high-level overwriting of electronic information, etc.
- Requirements for documenting the destruction of records, such as maintaining a document destruction log.
- Backups and redundancies and how they’re addressed in the destruction process (e.g., backups of electronic records).
Because of the crucial role records play in the operation of healthcare practices, staff members need to appropriately maintain and manage records throughout their lifecycle — from creation to destruction. Developing and implementing detailed record retention policies and procedures, providing appropriate staff training, and monitoring for compliance will help ensure consistency and accountability for record management.
For more in-depth information, see MedPro Group’s Record Retention guideline.
