Record retention made easy
Nothing raises more questions when closing a practice than what to do with the medical records. It is important to remember that the physical record (whether paper or electronic) is the property of the practice while the information in the record is the property of the patient. Thus the patient is entitled to obtain copies of the record, but the physician must retain the original in case a liability claim is filed.
- Retention rules vary by state. Contact state governments and/or a liability insurer for guidance, including the legal length of time records should be retained, and any other state-specific requirements. State medical societies may also have information.
- If no state-specific requirements exist, it usually is sufficient to keep original records until the statute of limitations expires or for 10 years from the date of the last visit. The records of a minor must be kept until the patient reaches the age of majority plus the time period for the statute of limitations. For example, if the age of majority is 18, the patient was 13 at date of last visit and the statute of limitations is 10 years, then the records must be kept for 5+10=15 years.
- Obtain written authorizations to transfer all patient records, particularly and specifically for sensitive information. Keep a copy of this authorization in the original record.
- When transferring medical record information, physicians may charge the patient a reasonable fee to reflect the cost of the materials used, the time required to prepare the material and the direct cost of sending the material. (Note: This fee may be determined by state law.) Physicians may make reasonable attempts to collect the fee in advance. Nonpayment or any outstanding balance, however, is not a reason to withhold records.
- Records must be stored in a place where they are safe from tampering, loss, fire, flood or unauthorized access. Some states allow transfer to microfiche or a read-only CD-ROM.
Other records, such as tax returns, bank statements, personnel files, explanations of benefits, and other financial records, also need to be retained.
- Keep tax returns, personnel files, accounts payable invoices, contracts and other financial records according to guidelines (usually seven years, but some states vary).
- Retain HIPAA documentation, such as acknowledgement of privacy notice, requests for amendments, and workforce training documentation, for six years.
- If using a professional service to destroy records, obtain certificates of destruction. Destruction can be by incineration, shredding, pulverization, or, in the case of computer media, reformatting or de-magnetization.
ACP Internist Weekly
From the September 23, 2014 edition
- Combination therapy for COPD associated with better outcomes
- GLP-1 agonist plus basal insulin beat other diabetes treatment regimens in meta-analysis
If you enjoy ACP Internist, sign up for ACP InternistWeekly, an electronic newsletter that covers the latest news in medicine. Click here to subscribe.
Join ACP Internist on Twitter
Get updates automatically and connect with members and other doctors by following ACP Internist's Twitter feed.
ACP Career Connection
Looking for a new internal medicine or subspecialty position?
ACP Career Connection can help you find your next job in internal medicine. Search internist and subspecialist positions nationwide that suit your criteria and preferences. Jobs are posted about two weeks before print publication of Annals of Internal Medicine, ACP Internist, and ACP Hospitalist. Exclusive “Online Direct” opportunities are updated weekly. Check us out online.
What will you learn from your Annals Virtual Patient?
Annals Virtual Patients is a unique patient care simulator that mirrors real patient care decisions and consequences. CME Credit and MOC Points are available. Start off with a FREE sample case. Start your journey now.
Products and Resources for Patients
ACP has developed easy- to-use materials designed to help educate your patients on self-management of a wide variety of common health conditions. Order yours today!
Prepare for the ABIM Certification Exam with ACP Internal Medicine Board Review.
Earn CME Credits through attending live meetings, working online, or watching course recordings on your own schedule.
ACP Depression Care Guide provides physicians with team-based practices for screening, diagnosis, and management of depression in primary care settings.