How old are your records? Here are some guidelines
Some documents will be like old friends
Learn to love your medical records; they’ll be with you a long time.
In many cases you’ll need to keep them at least a decade and as long as 30 years, according to the American Health Information Management Association (AHIMA) in Chicago.
The association is urging health information managers to develop formal policies outlining how long specific records should be kept. In most cases the parameters are spelled out by a complex array of state and federal laws.
"A solid retention policy for medical records and health information enhances the quality and continuity of patient care," says Linda L. Kloss, RRA, AHIMA executive vice president. "It also helps reduce liability risks and enhance an institution’s ability to monitor utilization and financial trends."
AHIMA says hospitals should adopt guidelines for what information needs to be retained, for how long, and how it should be stored, such as on paper, microfilm, optical disk, or magnetic tape. In a practice brief written by Gwen Hughes ART, and published in the January issue of the Journal of AHIMA, the association recommends using the following minimum time periods:
• Patient health records for adults: Keep 10 years after the most recent encounter.
• Patient health records for minors: Retain until the age of majority plus any specific statute of limitations.
• Diagnostic images (such as X-rays): Keep five years.
• Disease index: Retain for 10 years.
• Fetal heart monitor records: Keep 10 years after the infant reaches the age of majority.
• Master patient index: Keep permanently.
• Operative index: Keep 10 years.
• Physician index: Keep 10 years.
• Register of births: Keep permanently.
• Register of deaths: Keep permanently.
• Register of surgical procedures: Keep permanently.
Agency laws add to confusion
Researching the retention requirements is no easy chore thanks to a wide range of agencies and laws involved. Among examples cited by AHIMA:
• Medicare’s Conditions of Participation for Hospitals require the retention of medical records and radiology service films, scans, and images for at least five years.
• Medicare’s Conditions of Participation for State and Long-Term Care Facilities call for the retention of clinical records for the period required by state law or, in the absence of state requirements, for five years from discharge.
• Occupational Safety and Health Administration rules require the retention of medical records of workplace and related incidents for 30 years beyond the period of a person’s employment, except when the employee worked less than one year. These records must be made available to employees upon the termination of their employment.
• The Joint Commission on the Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, requires that retention policies be determined by law and regulation, as well as by use in patient care, legal, research, and educational activities.
The AHIMA practice brief also includes a summary of retention requirements in each state, along with a citation of the applicable law.
[Editor’s note: For more information, contact the Journal of AHIMA, 919 N. Michigan Ave., Suite 1400, Chicago, IL 60611. Telephone: (312) 787-2672]
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