How do you Know Which Patient Records to Retain?
Today we want to go over retaining records. How long should you retain medical records. There are a lot of factors that go into that and we’re going to go over these today.
When you think in terms of the length of time medical records ought to be retained, and you’re asking how long, you’ve got to realize that there are legal issues related to this, statute of limitations on lawsuits.
There are practical issues of storage, long term storage, and protection from fire and theft, that things like that. Security and logistical problems: finding them, accessing them, getting to them. Legal, practical, and logistical problems all feed into how long records should be maintained in this whole equation.
Now, the American Hospital Association recommends that you ought to maintain full records for a minimum of 10 years per patient or in the case of minors 10 years after they reach majority age. Ten years minimum for your adult patients and for minors 10 years after they reach majority.
You need to keep in mind federal and state statutes and regulations. What are the statute of limitations on certain things within your state or on the federal level? It does determine the maximum amount of time the lawsuit can be filed.
Federal and state statutes or regulations are important to keep in mind also, the organization that you work with. What are their policies in terms of record retention? Work together with your hospital administration, your organizations, administration to establish your retention and destruction schedule based on all these factors that you’ve looked at here.
As you’ve worked with them then stick to it, because there is a certain point at which you can say, “Okay, these records are just taking up space we can destroy them and eliminate them, but these other things need to be kept.”
With that in mind, the final thing is, the following patient information should probably be kept permanently (should never be scheduled for destruction): dates of admission, dates of encounters, and dates of discharge should all be retained for each patient.
The names of the physicians who are working with that patient, the diagnoses and procedures given to that patient, the patient’s history, the results of any physical exams the patient receive, operative and pathology reports, and then discharge summaries.
These things at a bare minimum should be kept permanently. Other things with these factors kept in mind can probably be put on the destruction schedule eventually. Well, these are just some of the issues related to record retention that need to be considered when you think about how long should we keep records.