A medical record contains information about the patient that is important for future and current healthcare providers to deliver the necessary care. Most providers rely on outsourced medical transcription services to maintain accurate and timely records of a patient’s identification information, medical history, medication history, family medical history, treatment history, and medical directives.
Good medical records are important for patients and physicians. A medical record contains information about a patient’s health and medical history. The level of detail and type of information will depend on the patient’s condition and the care they require. Insurance companies often request medical documentation during claim evaluation to determine reimbursement. Patients can request a copy of their medical record at any time.
So, for how long do hospitals need to retain medical records?
Factors Governing the Timeline for Medical Record Retention
There are multiple options for storage of medical records such as scanning to optical disk, use of microfilm or microfiche, and off-site storage. A record retention schedule is essential due to storage space restrictions, and the need to manage large volumes of information and facilitate easy retrieval.
Medical transcription companies help providers create medical records from physician dictation. The four steps in medical records management are: creation, utilization, maintenance and destruction. So the process begins when information is created and ends when the records are destroyed. While creating and using medical records is a fairly straightforward process, issues may arise when it comes to maintaining information. According to AHIMA, healthcare organizations need to manage record retention schedules to ensure:
- Availability of patient health information to meet the needs of continued patient care, legal requirements, research, education, and other legitimate organizational requirements
- Guidelines on what information is kept, the time period for which it is kept, and the storage medium (e.g., paper, microfilm, optical disk, magnetic tape).
- Clear destruction policies and procedures that include appropriate methods of destruction for each medium on which information is maintained.
Generally, the time medical records are kept ranges from five years to ten years after the death, discharge, or last treatment of the patient. Medical record retention time is impacted by state requirements, federal laws, and special population requirements.
- State Requirements: To establish their medical record retention, healthcare organizations need to refer to their state’s specific legislation or in the absence of such laws, retain health information for the length of time specified by the state’s statute of limitations. Federal laws require that medical records be kept for at least seven years after the patient receives the treatment, though the time has been sometimes extended to 10 years.
- Accreditation Agency Requirements: Accreditation agency standards also determine record retention guidelines. The Commission on Accreditation of Rehabilitation Facilities, Det Norske Veritas, Medicare Conditions of Participation, and the Joint Commission have record retention schedules in their accreditation survey processes (www.library ahima.org).
- Special populations: If the patient is a minor, the provider should retain health information until the patient reaches the age of majority (as defined by state law) plus the period of the statute of limitations. For e.g., in Nevada, healthcare providers are required to maintain medical records for a minimum of 5 years, or, in the case of a minor, until the patient has reached 23 years of age. Special records retention schedule rules may apply to Medicare patients, and behavioral health or research patients. For Medicare patients, the timeline for medical record retention is ten years. The FDA requires cancer patients’ research records to be maintained for 30 years.
Types of Medical Records and Retention Policy
To create a retention schedule, hospitals have to identify their active and inactive records.
Active records are documents that are being currently utilized and consulted on an ongoing basis. For example, the records of a patient who was seen a week or even a few months ago would be considered active. However, if the patient was seen over seven years ago, then the record may be considered inactive. Other active records consulted or used on a routine basis include those pertaining to release of information requests, revenue integrity audits, or quality reviews.
Inactive records are those documents that are not being currently used by the hospital such as those of patients who has not sought treatment for a period of time or have completed their course of treatment.
Physical file space, extent of research completed, and availability of off-site storage also determine whether a record will be categorized as active or inactive. To decide when a record becomes inactive, AHIMA recommends that organizations should have a cutoff point based on the following considerations:
- How often the records are accessed (daily, weekly, monthly, etc.)
- The total retention requirement
- Record size (large long-stay record or a short emergency record)
- Physical space constraints
- Activities or functions that call for routine access to the record (quality reviews, release of information)
Implementing and maintaining an effective filing system depends on identifying active and inactive records. The life cycle of a good record retention program ends when information has been destroyed in accordance with federal and state laws.
Does HIPAA have Medical Records Retention Requirements?
There is No Medical Records retention period under HIPAA and the Privacy Rule does not stipulate how long medical records should be retained. Organizations must follow the state’s laws governing the retention of medical records. However, HIPAA requires that HIPAA-related documents must be retained for a minimum of 6 years from when the document was created, or – in the event of a policy – from when it was last in effect (www.hipaajournal.com).
When it comes to medical documentation, HIPAA covers a lot of various complexities. For example, HIPAA compliant medical transcription companies that help providers maintain medical records have proper measures to ensure security, health care compliance and privacy of protected health information (PHI). Once the retention periods for medical records and HIPAA documentation has been reached, HIPAA requires physical and electronic forms of PHI to be disposed of using an appropriate destruction method.