Monday, Nov. 11th 2013

Medical Record Retention – Post career

        Retiring physicians have a lot of items on their checklist. They have to give advanced notice to patients so they can find another healthcare provider, send a signed letter to the DEA (Drug Enforcement Agency) to delete their DEA number, and contact every government-run or commercial health plan provider they do business with.  They might even need to shop around for a buyer to purchase the practice they are retiring from. Most of it is pretty straight forward and self-explanatory, except for one of the most important and impactful steps in the whole process: What should a doctor do with the patients’ medical records?

        If a doctor is selling the practice or transferring patients to a partner, then the documents will typically just go with the other practice. The doctor has to have something in writing to reflect that, either a signed, written statement or a sales document.  That’s simple enough, but what if the practice is closing? Let’s say a doctor doesn’t (or can’t) sell the practice and it’s just shutting down…

        How long does a practice need to retain medical records?  The span of time required varies with local and state law, but typically it’s anywhere from five to ten years, with a few factors or circumstances that could affect that. For example, in Kansas (K.A.R. 100-24-1) it is ten years from date of last treatment, with some exceptions. Some states don’t even have a law or guideline at all for how long to maintain medical records, but that maintaining medical records for a long period of time doesn’t just benefit the patient. Of course the patient’s well-being and medical needs are the number one concern, but those records can assist in a doctor’s defense in dealing with a medical malpractice claim. The statute of limitations is two years, so at the bare minimum records should be kept for that long.

         Some patients might expect their records to be kept “forever.” Doctors are under no obligation to do so, but they may want to contact patients they have not seen in seven years and ask if the patient wants to maintain their records further.

        Medical records for patients not treated in more than 10 years, what about those?  Any and all medical records that a doctor is no longer legally bound to keep should be disposed of, and not just thrown away. Records should be destroyed so that there’s no chance anyone could access a former patient’s sensitive information. A professional record-shredding service is best for the paper documents, and the local hospital should be able to take care disposing of any charts or X-rays.

        How can records be stored? Should all the records be kept in paper form? There aren’t any requirements for the media formats of medical records, so long as the medical record stays in it’s the original form or a legally reproduced form.  However, “legally reproduced” means the records were converted from their original paper form into a digital format or scan, and this imaged/scanned reproduction has to be identical in every way. All of the footnotes, any writing in the margins, a smudge, all of it has to be a perfect match to the original, and it must then pass a certification/quality assurance process.  Paper records should only be destroyed if the records are certified as an acceptable reproduction.

        Medicare contractors, state statutes, and professional licensing agencies can help with state-specific requirements or recommendations.  The easiest way to take care of everything covered in this blog, is to hire Copies F.Y.I and let us assist.

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