Medical record retention continues to be a significant issue for health care providers. Having confidence in your ability to determine appropriate eligibility for destruction is key to maintaining a defensible position. Trying to find clarity and direction through state laws can be challenging given the age of some state laws, the limited wording about retention triggers, and their focus on hard copy storage.
Disposition triggers are crucial to effective management of records, yet state laws often contain language that lack clarity about which types of medical records need to be retained, in what format, and specifics on lifespan of a patient's history. Healthcare providers are often under pressure to reduce volume and storage costs for records. How should state laws be interpreted in order to sustain a defensible disposition?
Ideally a law should clearly stipulate requirements for retention and disposition of records to avoid uncertainty. The reality, however, is that organizations must make decisions based on current language in the law. In the absence of clarity, some providers retain records cumulatively to reduce risk of premature destruction and loss of valuable data, while others have chosen incremental destruction, which may create gaps in the overall medical history, but reduces short-term storage costs. Understanding the risks involved in the interpretation of disposition triggers and ensuring consistent compliance becomes a critical issue.
In time, the less-than-clear state laws may be revised for clarity, specify the need to retain cumulatively, and identify procedures for electronic records. Until then it is recommended that providers take the initiative to define their level of risk over the long term, document its policies and procedures, implement accordingly, and ensure consistency in disposition practices. Here are factors to consider:
Are there quality of care or legal obligations to retain a medical record cumulatively to ensure the physician has access to the full patient history?
Have you considered the risks in not having legacy patient information available when a patient returns, if incremental destruction is occurring?
Do your policies and procedures address the specific types of records that must be retained and identify the disposition trigger for all types of records?
Are you well-equipped to manage destruction consistently to avoid legal issues and penalties?
These are important questions that impact risk, costs of retaining or destroying, and compliance with state laws. If your organization has not yet brought together Legal, Compliance/Risk, IT, and HIM groups to develop policy, consider the benefits that can be achieved and begin the process. Identifying a defensible, practical, and achievable strategy that can be implemented consistently over time is paramount.
Local, regional, or national professional associations are a good place to voice issues and share concerns. Your participation in these forums will increase visibility and leverage our collective knowledge. And, by working with an expert partner, you can leverage their learnings and experience to implement policies that can directly impact your volume and costs, and help achieve consistency in medical record retention.
If you would like to learn more about this important topic, you can register for the informational webinar: Retention Management: An Enabler for Information Governance.
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Medical record retention continues to be a significant issue for health care providers. Having confidence in your ability to determine appropriate eligibility for destruction is key to maintaining a defensible position. Trying to find clarity and direction through state laws can be challenging given the age of some state laws, the limited wording about retention triggers, and their focus on hard copy storage.
