Patient Record Retention and Medical Practices: What is Required?

Medical records are the foundation upon which everything related to the patient is built. They contain all the information regarding a patient that is relevant to him or her medically. They are necessary for any doctor. They help you keep personal and medical data when it comes to your patients which is beneficial for both you as a physician and for patients. The medical data that is acquired over time and added to a patient’s record can help doctors create better management plans because they have all the data they need. For instance it could say on a patient’s record that they’re allergic to certain drugs which will help you avoid giving them these medications. This may have caused a problem if the patient forgot to tell you or for instance they were admitted unconscious and you had no way of knowing.

You can also use these records to keep track of how patients are doing. One simple example is by tracking a hypertensive patient’s blood pressure measurements over time which will tell you if their hypertension is properly controlled or not. A diabetic may require a few trials of medications before you finally settle on what works best for them and medical records can help you keep track of that.

Of course you wouldn’t need medical records if you only had one patient your entire life because then it wouldn’t be difficult to recall their information. Since that’s not the case, however; and you have dozens of patients it’ll be impossible to remember everything about each patient.

There are two relatively new types of medical records: EMRs and EHRs. EMR stands for Electronic Medical Record which is created at each practice only to be used by that practice. It is all the medical information about your patient since the day they stepped into your office. Only you can use that EMR and no one else can access it but you.

An EHR stands for Electronic Health Record. This is more universal than an EMR. It is created as soon as possible for a patient and follows them throughout their life. Any new medically relevant data is added to a patient’s EHR. It is also shared by all of the patient’s physicians, hospital, and the patient can access it too. This makes it of more use than an EMR because it has so much information and is not limited to one single practice or doctor.

Of course there’s the issue of maintaining these records. Medical information isn’t just based on electronic records but there are also files, CDs, images, and more. It’s important for a hospital or practice to find a way to maintain these records and make sure they’re secure so they don’t fall into the wrong hands. Medical records are very sensitive and it could be a major problem if they were accessed by someone who has no right to see them. That’s why destroying these records is also important and needs to be done adequately.

File space can also be a problem hospitals may face. With so many patients coming in everyday and each undergoing investigations and treatments it can be hard to find storage space for all of these files. With new technology emerging these records may be scanned in order to be saved electronically or they may be stored at an off-site storage space. Of course storage problems are becoming less of an issue with the emergence of electronic records.

For these reasons it’s important to create a clear and well defined record retention plan. It’s necessary to have a clear idea of how long to store medical information and when it’s okay to destroy them and not keep them any longer.

Every medical organization such as hospital or practice needs to have clear intentions and outlines when it comes to medical records. These ideas must cover a few things. First, it’s important that medical records are available to provide continued medical care to the patient, legal requirements, education, and research. Second, it’s important to have guidelines that dictate how long certain information is retained for and the form in which they’re retained such as files or on tape. Finally, organizations need to have clear rules on destroying these records such as how it’s done and specifics related to the form of data.

So how long should records be kept before they’re destroyed? Like we said it would be impossible for a hospital to keep the files of every single patient that has entered it since the day it was established and until the end of time. The timing isn’t arbitrary and most states have rules and regulations about when it’s accepted to destroy records. Otherwise we’d have records being destroyed the moment a patient walks out of a hospital or clinic thinking they won’t be needed only for the patient to come in for another visit the next few days.

Here are a few states and the medical record retention time required by law:

-In Alabama a hospital must retain records for at least 5 years after discharge. If the patient is a minor then the records should be maintained for 5 years AFTER the patient reaches adulthood. On the other hand, the retention time for physicians isn’t as restricted as it is for hospitals. Physicians must maintain the records for the duration of the patient’s treatment and for as long as necessary medically or legally.

In the District of Columbia hospitals must maintain records for 10 years after the patient’s discharge or for 3 years after patient who was a minor becomes 18 years old. As for physicians they’re required to retain records for at least 3 years after they last see the patient or for 3 years after a minor becomes 18 years old.

In Florida the rules are pretty straightforward. Physicians need to maintain records for 5 years after their last contact with a patient while hospitals need to maintain them for 7 years after a patient’s last entry.

In Oklahoma there is no required minimum duration to maintain records. It is left according to the patient’s condition and the physician’s assessment.

If there is, however, a medical or legal reason to keep these documents for longer, then they should be kept until that reason is over and no longer requires them.

Now that we’ve talked about state regulations for keeping medical records let’s talk about how to destroy various forms of records after the minimum maintenance duration is over:

• The most common type of medical record is a paper record and ways to destroy paper records include burning, shredding, and pulverizing.
• Laser discs and microfilms are destroyed by pulverizing.
• DVDs are destroyed by cutting.
• Data that is computerized is destroyed by magnetic degaussing.

Keeping certain information regarding the destruction process such as the date, method, description, inclusive dates, and the signature of the person responsible for the destruction process is also necessary to ensure that the process is done adequately and that it was supervised.

It’s essential to carefully follow the instructions for destroying records because what good does it do to safely keep a record for 7 years then simply dispose of it incorrectly and having it end up in the wrong hands?

Medical information is very essential and sensitive to all of us. There’s a reason doctor patient confidentiality is such a big deal. There’s very little that we can consider more private than our medical information and none of us would want to have it revealed to anyone.

It’s important to keep records for a certain time because they might be of use medically or even legally. They may aid a patient on following visits or be the decider in a lawsuit. The entire process is very complicated and perhaps in the future there will be ways to make it simpler such as online records, but for now keeping in line with the rules and regulations is the best thing to do.