Know how long to keep that health information
There is no need to maintain duplicate MPIs
Now, more than ever, health information management (HIM) personnel need to ensure that the health information they maintain is available and relevant.
To do this, they must know how long to retain the different types of health information. The American Health Information Management Association (AHIMA) in Chicago is helping with this effort by publishing an updated practice brief on the retention of health information.
Every health care provider should develop a retention schedule for patient health information that meets the needs of its legitimate users and complies with legal, regulatory, and accreditation requirements, according to the brief, prepared by Donna M. Fletcher, MPA, RRA, HIM practice manager for AHIMA.
The retention schedule should include guidelines that specify what information should be kept, the time period for which it should be kept, and the storage medium, such as paper, microfilm, optical disk, or magnetic tape. The documentation should be retained according to applicable federal and state law and regulations and must be maintained for a sufficient length of time to ensure its availability to prove compliance with laws and regulation.
"The majority of states have specific retention requirements that should be used to establish a facility’s retention policy," Fletcher says in the brief. "In the absence of specific state requirements for record retention, providers should keep health information for at least the period specified by the state’s statutes of limitations or for a sufficient length of time to prove compliance with laws and regulations."
If the patient is a minor, the provider should retain health information until the patient reaches the age of majority (as defined by state law) plus the period of the statute of limitations, unless otherwise provided by state law.
A longer retention period may be the preferred course of action, since the statute may not begin until the potential plaintiff learns of the causal relationship between an injury and the care received. In addition, under the False Claims Act, claims may be brought for up to seven years after the incident; however, on occasion, the time has been extended to 10 years.
In the absence of applicable laws or regulations or unless longer periods of time are required by state or federal law, AHIMA has published its own recommended retention standards. (See chart, above.)
AHIMA also included tables outlining accreditation agency retention standards, federal health record retention requirements, and state laws or regulations pertaining to retention of health information in its brief. (The tables can be viewed on the association’s Web site at www.ahima.org/ publications/2a/pract.brief.699.html.)
For the most part, health care facilities are retaining health information appropriately, Fletcher says. What they don’t need to retain are duplicate master patient index (MPI) files on cards or in other systems.
"When you have a master patient index that is on one system and you are converting to a new system, invariably there are going to be duplicates," she says. "For example, two patients may have the same medical record number or you may have one patient with more than one medical record number."
The duplicates should be cleaned up before the conversion takes place, she says.
With paper files, HIM personnel could check several different types of patient information to ensure that the physicians were receiving the correct files. Now, computers check for that information automatically. This can create a problem if admission personnel only asked for a person’s name and did not verify the spelling.
"There are a lot of variations in the spelling of a person’s name," Fletcher says. "It could be Smith, Smyth, or Smithe. "The assumption can be made that this patient has not been seen before when in fact he has been in the facility multiple times," she continues.
This misunderstanding may result in the patient not receiving proper treatment because the physician does not know the patient’s medical history. To address this problem, facilities should have guidelines for inquiring of the MPI in the appropriate manner, Fletcher says. For example, patients could be asked for a driver’s license, social security number, date of birth, and full name.
"With electronic records, [the correct inquiries] are more important now than ever." n
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