What does it mean to retain medical records?
Medical records retention involves keeping a record of your patient charts and other medical information. By maintaining these records, you establish a history of your treatment plans and the quality of care provided. This is particularly crucial in value-based care models, where the assessment of care quality plays a significant role.
Proper retention of medical records is recommended for effective long-term patient treatment. Additionally, it proves beneficial in situations such as medical malpractice lawsuits, licensing board complaints, and medical billing audits.
Various factors influence the duration for which medical records should be retained
Federal laws outline specific guidelines for record retention:
- Centers for Medicare & Medicaid Services Hospital Conditions of Participation and Interpretive Guidelines:
- A minimum six-year medical record retention period applies to critical access hospitals, exceeding the standard requirement.
- Occupational Safety and Health Administration (OSHA) hazardous substance rules:
- Under OSHA regulations, if medical personnel encounter detrimental health effects from exposure to harmful agents, the retention period for exposure records extends to 30 years.
- Health Insurance Portability and Accountability Act (HIPAA) privacy regulations:
- For compliance with the HIPAA Privacy Rule, a six-year retention period applies to policies, procedures, and disclosure accounting documents.
State laws also play a crucial role in determining record retention requirements:
- In California, practitioners must keep certain medical records for a minimum of 10 years.
- The requirement for medical record retention is six years, with an extended retention period for obstetric and pediatric records until the child attains the age of twenty-one.
- Texas practitioners must keep medical records for at least seven years, except for pediatric records which must be retained until the child turns 21.
Additionally, case law, a subset of state law, addresses the duration within which patients can file medical malpractice suits after discovering that malpractice led to their current complaints. Consulting with experts in your state can provide further insights into these regulations.
Best practices for keeping and maintaining medical records
- Know what to record:
- Include demographics, reason for visit, exams, tests, findings, diagnoses, treatment plans, prescriptions, and medications.
- Retain records from external physicians and specialists based on the same time frames.
- Record and store information correctly:
- Keep notes objective and timestamped.
- Indicate informed consent, patient refusal, or noncompliance.
- Avoid illegible writing, abbreviations, offensive language, or alterations without a record.
- Store records in a medical office or warehouse, not residential locations.
- Prioritize confidentiality:
- Patient consent is usually required for sharing records.
- Ensure HIPAA-compliant EMRs with proper safeguards.
- Limited exceptions exist for emergencies and specific public health programs.
- Make records accessible to patients:
- Set up systems for easy patient access, complying with their requests to share records.
- Destroy records appropriately:
- Ensure confidential information remains private during destruction.
- Consider hiring a record destruction agency and maintain a log of destroyed records.
The Right Tools for the Job:
Investing in HIPAA-compliant medical software can streamline recordkeeping. Here are some top picks:
- Tebra: Easy-to-use interface and social media-style dashboard.
- athenahealth: Simultaneous view of new and old data for consistent recordkeeping.
- AdvancedMD: Built-in voice-to-text tools for clear and concise notes.
- CareCloud: Preset and customizable templates for organized records.
- DrChrono: Ability to draw on diagnostic images for enhanced clarity.
By following these guidelines and leveraging the right tools, you can ensure your medical records are accurate, secure, and readily available – protecting your story and facilitating better healthcare for everyone involved.
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