If you are in the healthcare industry, records are a fundamental part of your business. Documenting a patient's medical history is vital, and you may have information dating back decades. Building a records retention policy can feel overwhelming, but it doesn't have to be. Here are a few tips on how to develop effective medical record retention policies.
First, start with understanding the regulations for your industry, which vary by state. These regulations define how long you need to retain patient records. For example, the rules define if there are different requirements for minor and adult patients, the requirements for a medical doctor versus a hospital, and how long to retain documents after a patient's death. Use resources such as HealthIT.gov to learn about your state's specific requirements.
Next, you should set a standard to define which files are considered active vs. inactive. The active files will be those you regularly use, such as with patients who make routine visits. For those patients who have not sought treatment in several years, you may label their files as inactive. These files will require less frequent access. The American Health Information Management Association has recommendations to help you make this determination.
Once you have determined which files you need to access frequently, develop an organization system to keep these active files handy. An alphabetical organization system of file cabinets for these active files is simple to implement. But your inactive files will require more work. Consider if you want to scan and index these files or store them offsite. Investigate the assistance of a documentation management firm like R4 Services that can consult with you and determine the most efficient solution for your needs.
Once an inactive file has passed its requirements for access, you don't need to continue to hang onto it. Instead, develop a plan to review your inactive files routinely, and flag those that no longer need to be retained. Determine a method for destroying electronic and paper files to ensure the private information is secure and you adhere to HIPAA standards.
Lastly, properly training your staff on retention procedures is essential to your policy’s success. Ensure that your retention policy is adequately covered in your employee handbook and whenever you onboard new employees. Additionally, consider running periodic training sessions to keep your staff updated on best practices and make them aware of any changes to your retention policy.
Developing a comprehensive records retention policy isn’t just about keeping you and your staff better organized; it’s also necessary to stay compliant with the law. At R4 Services, we’ll work with your healthcare organization to help you meet compliance requirements and optimize your records management process. Contact us today to get started.