Accurate medical records are essential to proper patient care. Records need to be updated frequently, with changes to key information such as changes in address, last name, prescriptions, or diagnosis. Meticulous recordkeeping is crucial to ensure that a patient receives quality care. Records retention is crucial element of an effective records management program.
Records retention is the process of keeping records according to their retention requirements. This means preserving important health information about a medical facility, procedure, or legal issue.
According to Referral MD, patient charts cannot be located on 30% of visits. This is one of the reasons there has been a big incentive to move all medical institutions onto EHR (Electronic Health Record)/EMR (Electronic Medical Record) systems. If all patient information is in a secure database, the possibility for patient information to be lost or misplaced can be drastically reduced.
Electronic Health Records (EHRs)
Electronic Health Records (EHRs) are a way to keep, access, change, and update records digitally, using computers, tablets, or other devices. An EHR is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. EHRs can contain information such as a patient’s medical history, diagnosis, medication, treatment plans, immunization dates, allergies, radiology images, or laboratory test results. In addition, EHRs can allow access to evidence-based tools that providers can use to make decisions about a patient’s care and automate and streamline provider workflow. However, the adoption of EHRs is still relatively new and does not typically include any legacy paper health records.
Retention of Paper Records After Converting to EHRs
Since the Electronic Health Record field is still new and evolving, many healthcare institutions still need to maintain paper records according to their retention schedule. It is crucial for healthcare institutions to have a trusted system to automate the retention and disposition of records. In addition, it’s wise for healthcare facilities to have a documented records retention policy with quality control procedures that ensure paper records can be located in a timely manner when needed.
Breakdowns in communication and lack of proper documentation can lead to increased litigation risk. Having trusted retention and records management policies are key to avoiding litigation. EHR-related malpractice claims are rising, and it is more important than ever to have a risk-mitigation strategy. Healthcare IT News recently reported that malpractice claims for issues that were caused by or a contributing factor of electronic health records errors have raised significantly. Federally-funded health centers are covered by the Federal Tort Claims Act (FTCA) for medical malpractice actions arising out of errors involving medical records. The FTCA was established in 1946 and is the legal mechanism for compensating people who have suffered personal injury due to the negligent or wrongful action of employees of the U.S. government. A federal tort claim must be filed within 2 years.
There are several variables that affect the length of time healthcare institutions should keep medical records including state and federal laws as well as medical board and association policies. There is a difference in laws between keeping paper and electronic health records. For example, in the Kentucky Office of the Inspector General, if the records can be accessed and accurately produced, there is no requirement to retain paper versions. The destruction of records should only occur in compliance with a written internal policy and after the information in the electronic record has been verified as accurate.
It is important for medical institutions to review malpractice insurance and be aware of the expectations of their insurer regarding record retention. Different carriers may have guidance or requirements for planning record retention policies.
The accuracy of a complete health record is documentation integrity. According to the Medicare General Information Eligibility and Entitlement Manual, “Disposition for Medicare Records that are Imaged/Scanned,” the Electronic Record Image must be identical to the paper. If an identical image is scanned, switching records to digital will minimize the chance of transfer issues and misplacing the records. In addition, a scanned record must be tamper-proof.
A provider’s records serve no purpose if they cannot be read. It is important that all writing and text in a converted document is legible, including text in footnotes and margins. If information is missing from EHRs, the records will not be fully merged and may result in missing, incorrect, or incomplete information. In addition, this can cause safety and privacy concerns for the patient and the healthcare institution. If only certain parts of a paper record are scanned into the EHR, a paper record is necessary to ensure the full health record can be available.
There is no single, definitive guideline regarding how long to maintain medical records. Laws vary by state. Generally, medical records are kept anywhere from five to ten years after a patient’s latest treatment, discharge, or death. The length of time records are retained also depends on whether the patient is an adult or a minor. Using a trusted records management system will ensure consistent and seamless management of remaining paper-based media across clinics, departments, and locations.