When it comes to medical records, adhering to a strict document retention and destruction policy is important. Failing to prioritize this can wreak severe consequences for your healthcare practice.
State law dictates medical record retention and destruction requirements, but healthcare facilities often encounter challenges in meeting these guidelines. The widespread use of electronic health records has led to a significant volume of records for healthcare providers to manage and store.
And with it came storage challenges. This article will discuss the challenges of proper record keeping and disposal of sensitive medical records.
What is a Document Destruction and Retention Policy in Healthcare?
A document retention and destruction policy in healthcare refers to a set of guidelines and procedures that dictate how custodians store, manage, retain, and ultimately destroy medical records and other PHI. This policy maintains patient confidentiality, protects sensitive information from unauthorized access, and complies with legal requirements.
While state laws govern the retention and destruction of medical records, it’s ultimately the healthcare facility’s responsibility to establish and implement a policy that is compliant with these regulations.
A document retention and destruction policy should contain the following information at a minimum:
- Detailed information on how your organization manages medical records,
- What types of records require a retention and destruction process,
- Minimum duration of document retention and how long your organization will maintain documents,
- Document destruction process
Additionally, it’s important to ensure all medical records clerks and other ROI staff understand your organization’s policy. Creating and sticking to a strong document destruction and retention policy in healthcare has countless benefits that make the effort worthwhile.
Why Proper Medical Records Management is Important?
Proper records management keeps patients’ protected health information (PHI) secure and confidential. With the rise of data breaches and cyberattacks in healthcare, maintaining a strong document retention and destruction policy is more important than ever.
Failure to properly manage medical records can result in serious consequences, including steep HIPAA fines and damage to your practice’s reputation. Inadequate storage or disposal of records can lead to data breaches. When this happens, you violate patient trust while also risking their personal and financial information.
According to AHIMA, between 8-12% of EHRs in a given system are duplicates. This creates an additional financial burden for patients and adds overhead costs to healthcare operations.
Does HIPAA Affect Your Medical Document Retention and Destruction Policy?
The Health Insurance Portability and Accountability Act (HIPAA) is the northern star of healthcare regulations, but it does not include guidelines for medical record retention. Rather, state regulations determine these minimum retention regulations.
However, when the time comes for destruction, HIPAA requires that custodians dispose of sensitive documents in a manner that renders them unreadable, indecipherable, and impossible to reconstruct.
A HIPAA settlement from 2017 that cost over $1.2 million illustrates the importance of proper and thorough record destruction. In this incident, the healthcare organization returned printers to a leasing company without deleting the PHI that they used them to copy.
Non-compliance with these guidelines can result in severe penalties, including heavy fines and reputational damage.
Medical Document Retention Under HIPAA
- Access to Records: HIPAA mandates that patients must have access to their Designated Record Set for six years from their last effective date.
- Retention of HIPAA-Related Files: Policies and procedures, privacy practices notices, disposition of complaints, and other actions, activities, and designations that the Privacy Rule requires to be documented must be retained for six years from the date of its creation or the date when it last was in effect, whichever is later.
- State Laws: While HIPAA doesn’t mandate a specific retention period for medical records, so state laws determine this factor. For example, Arkansas requires adult hospital medical records to be retained for ten years after discharge, while North Carolina stipulates that hospitals must retain medical records for eleven years after patient discharge or until a minor patient reaches 30 years old.
- Data Protection: HIPAA requires covered entities (CEs) and business associates (BAs) to apply appropriate administrative, technical, and physical safeguards to protect the privacy of PHI, in any form, including during its disposal.
Destruction of Medical Records Under HIPAA
HIPAA has precisely outlined the requirements for the disposal of medical records, underscoring the essentiality of maintaining patient confidentiality and preventing unauthorized access to Protected Health Information (PHI).
- Destruction of PHI: By HIPAA regulations, custodians must destroy PHI in a manner that prevents reconstruction. This applies to both paper and electronic records. Approved methods for disposing of paper records include burning, shredding, pulping, and pulverizing.
- Disposal of Devices With Scanners: Fax machines, printers, and scanners maintain memory of the scanned documents. Disposal or destruction of such devices requires custodians to wipe their internal memory first.
- Disposal of Unused Media Containing PHI: Custodians shouldn’t haphazardly discard media that contain PHI in dumpsters or waste bins. Instead, HIPAA mandates that custodians completely destroy the media.
- Disposal Vendor: While HIPAA does not explicitly require the engagement of a disposal provider, many organizations opt to contract with a disposal vendor to ensure compliance with the regulations.
- End of State-Mandated Retention Period: Upon the conclusion of the state-mandated medical record retention period, the destruction of PHI must meet HIPAA guidelines.
Disadvantages of Paper Records in Retaining Medical Documents
HIPAA is instrumental in dictating how healthcare institutions handle medical documents, emphasizing heavily the necessity of patient privacy protection. The guidelines stipulate strict measures to maintain the integrity of PHI during storage and disposal.
However, following such stringent guidelines can be challenging when using traditional methods like papers and filing cabinets.
Disadvantages of paper medical records storage include:
- Limited storage: The physical nature of paper documents necessitates storage space. This can quickly become a significant issue as the volume of records increases, leading to clutter and disorganization.
- Security concerns: Protecting physical documents from unauthorized access or theft can be challenging. Unlike digital records, it’s not possible to encrypt paper documents, leaving them vulnerable to security breaches.
- Vulnerability to damage: Paper documents are susceptible to damage from various sources, such as fire, water, pests, natural disasters, and even natural decay over time. This vulnerability can lead to the loss of critical medical information.
- Document transportation: The physical transfer of paper records from one location to another can be problematic and potentially risky. There is a risk of loss or damage during transit, compromising the integrity of the information.
- Poor searchability: Retrieving specific pieces of information from paper-based records can be a time-consuming and laborious process. The lack of standardization across physicians and healthcare facilities further compounds this issue.
- Volume and cost: The sheer volume of paper records can lead to substantial costs in terms of storage and management. These costs can strain the financial resources of healthcare facilities.
- Reliability and Inability to duplicate: If a paper record is lost, damaged, or destroyed, there may be no backup copy available. The absence of this aspect can jeopardize the continuity of patient care.
- Inefficiency in a digital world: In an increasingly digital world, traditional records management practices may prove to be insufficient and ineffective. This inefficiency can lead to delays in patient care and increased operational costs.
Digitization and Cloud Storage as a Solution
Digitizing medical documents solves the challenges associated with paper-based records. It improves compliance with HIPAA regulations by providing secure document retention and destruction processes.
Some of the key benefits of digital records include:
- Instant sharing and collaboration among healthcare professionals, improving efficiency and quality of patient care.
- Increased security with encryption and unique access controls. This ensures that only authorized personnel can access the data, further enhancing the security of PHI.
- They can be backed up in secure locations, protecting against data loss due to natural disasters, system failures, or human errors.
- Digital records can be permanently and efficiently destroyed without spending hours at a shredder, ensuring that PHI cannot be reconstructed.
- Digital systems offer scalability, effortlessly accommodating growing healthcare practices by handling increased record volumes effectively.
As technology continues to advance, healthcare facilities need to embrace digital solutions to remain competitive and provide quality patient care
How ChartRequest Boosts EHR Transmissions and Keeps Them Compliant
ChartRequest is an innovative and reliable Release of Information (ROI) platform designed to facilitate fast and secure EHR sharing. It helps healthcare providers to streamline their medical information transfer processes, ensure compliance with regulations, and improve overall patient care.
- Efficiency: ChartRequest revolutionizes the process of sharing and requesting medical records by automating the entire workflow. This saves valuable time and reduces the risk of human error, ensuring accuracy and reliability in record transmission.
- Compliance: The platform strictly adheres to the guidelines set by HIPAA. With robust security measures in place, ChartRequest guarantees compliant and secure EHR transmissions, safeguarding patient privacy and confidentiality.
- Audit Trails: ChartRequest goes beyond just facilitating record requests and releases. It offers a comprehensive audit trail for each information transaction, providing a detailed account of who accessed, shared, or modified the records. This fosters accountability and transparency, crucial in maintaining the integrity of medical information.
- Streamlined Workflow: With ChartRequest, healthcare providers can streamline their information management workflow by centralizing all requests in one place. This eliminates the need for manual coordination and tracking, reducing administrative burdens and improving overall efficiency in healthcare facilities.
- Improved Patient Care: By enabling fast and secure access to health records, ChartRequest empowers healthcare professionals to make informed decisions and deliver personalized and timely care. It ensures that critical information is readily available, resulting in improved patient outcomes and satisfaction.
- Scalability: As a digital solution, ChartRequest is designed to scale effortlessly to meet the needs of healthcare facilities of any size. Whether it’s a small clinic or a large hospital network, the platform can accommodate increasing volumes of information requests without compromising performance or security. This scalability ensures that ChartRequest remains a reliable and future-proof solution for healthcare organizations.
ChartRequest Aids Document Retention and Destruction Policy
ChartRequest plays a crucial role in centralizing medical records on its platform, simplifying the process of managing and securely disposing of digital documents. All medical records are consolidated in one digital space, ensuring easy access and efficient management. Digital documents can be stored securely and indefinitely, eliminating the limitations of physical paper-based storage.
ChartRequest also ensures compliance with HIPAA regulations when disposing of obsolete records, minimizing the risk of unauthorized access or data breaches. This centralization improves efficiency and compliance. It also enhances patient care by providing a comprehensive and accessible digital history of their healthcare data.
Business Associate Agreement
The document retention and destruction policy is further strengthened by ChartRequest’s Business Associate Agreement.
This agreement ensures that ChartRequest is held accountable for maintaining the confidentiality and integrity of PHI following HIPAA regulations. It also outlines specific responsibilities, such as providing training on privacy and security policies to its employees, reporting any breaches or violations, and conducting regular risk assessments.
By utilizing ChartRequest’s ROI platform, healthcare facilities can effectively manage their document retention and destruction policies while
ChartRequest — Your HIPAA Compliance Partner In Medical Records Management
A comprehensive document retention and destruction policy is crucial in the healthcare sector, as it brings several advantages. These include improved accessibility, enhanced security, and streamlined workflows. The digitization of medical documents and the adoption of cloud storage represents a significant leap forward, addressing the limitations of traditional paper-based records while ensuring compliance with stringent regulations like HIPAA.
ChartRequest is an ideal partner in this evolution, providing an efficient, scalable, and secure platform for EHR management. Its robust features such as automated sharing, detailed audit trails, and a compliance-driven approach ensure that healthcare facilities can operate with confidence and efficiency.
If you’re seeking a solution that simplifies your document management process while adhering to compliance standards, it’s time to consider ChartRequest. Embrace the digital transformation and boost your healthcare facility’s records management strategy with ChartRequest by booking a demo today.