Believe it or not, there is an entire industry dedicated to the management of health information. It goes back to the 1920s when healthcare providers began to understand the benefit to both patient and doctor of well-documented medical history. Through accurate recording of patient care, doctors were able to advance the quality and safety of treatment. Eventually, documentation became standardized – thus, the patient medical record was born. A
lmost a century in, the question of how long you need to keep medical records is becoming a big issue for health care providers.There are several dates to consider when considering how long records need to be kept. One of course is the death of the patient, another is the termination or merger of a particular medical practice, or the death of the doctor. What if litigation is involved? Does the record live in perpetuity in a legal office file?
Paper files take up a lot of physical space, and they also use a lot of natural resources. As environmental concerns grow and real estate and rental costs skyrocket, dedicating square footage to files becomes problematic.
In 2009, as part of an economic stimulus package in the wake of the financial crisis that ensued when the housing bubble burst, the 111th Congress under the Obama Administration passed legislation requiring all health care providers to demonstrate “reasonable effort” to convert paper medical records to electronic media. The incentive lay in tying Medicare and Medicaid insurance payments to electronic medical record (EMR) conversion.
Medical Record Retention Guidelines
With every government regulation comes a series of parameters, and herein lie the medical record retention guidelines. Each state has the right to set its own guidelines, but this can become an issue for patients with long histories who move to different regions of the country. Furthermore, since EMR Conversion practice didn’t go into full effect until January of 2014, hundreds of thousands of patients across the country likely have a combination of paper and digital histories.
A deep dive into Google will yield hundreds of responses to the query “how long do you have to keep medical records?” yet, there is no definitive answer. That’s where medical record retention guidelines come into focus.
As a general practice, most hospitals and health care providers keep patient medical records for 10 years. It gets complicated however, when you consider when that 10-year clock starts ticking. Is it 10 years from the last day of service, or from the death of the patient, or after the death of the provider?
How Long Do Hospitals Keep Medical Records?
Again, there is no standard answer. Circling back to State’s Rules that allow each state to determine how long records must be kept, there are different governing bodies within the medical community that have various or conflicting record retention guidelines.
For example, Medicare requires that records be kept for five years, and six if the hospital meets critical care access standards. OSHA (Occupational Safety & Health Administration) mandates that records be kept for 30 years in cases where the patient has been exposed to or treated for toxic substances. Furthermore, record retention guidelines are different if the patient is a minor or an adult.
Are Doctor’s Record Retention Guidelines the Same as the Hospital’s?
Given that most medical doctors are affiliated with a hospital where they have admission access, they generally follow the same retention standards their admitting healthcare system does. In cases where a medical service provider is not affiliated with a hospital or other treatment facility, they are still subject to the regulations established by the state in which they practice.
Regardless of whether a practitioner is affiliated with a hospital, they are subject to the same regulations when it comes to keeping records. A doctor cannot refuse to release medical records to a patient. HIPAA privacy rules can prevent the doctor from releasing the same record to a third party. In some psychotherapy situations, for example, a doctor may restrict the amount of information released to the patient, but in general terms, no personal medical record can be withheld from a patient who requests it.
Electronic Medical Records
Going forward, the use of digital media for patient medical records may change the way data is stored. It may also affect guidelines and regulations regarding how long that information must be saved.
Thankfully, technology advancements allow for increasing volume of data and more efficient transmission of information. Someday, when EMR conversion is complete, medical and healthcare providers will no longer have to consider physical storage of patient files as part of their expenses, nor will they have to worry about their carbon footprint, which may free up more time to focus on the quality of patient care and treatment.