August 2012

August 2012

Patient documentation must be kept on file for 5-10 years, depending on your state law. For patients under 18 years of age, 5-10 year period begins once they turn 18. Where and how long you keep records on file is an important component of your compliance policy. With electronic health records (EHR) more offices are archiving patient records electronically to save space and keep records even longer.

Some malpractice carriers advise you to keep records indefinitely. Space constraints can often make this difficult. Here are a few suggestions:

1) Scan patient records into an electronic format, even if you don't use EHR. Use your paper files only for the most current day-to-day use. Scan completed episodes of care and other records to a network drive or other device that is backed up.

2) Periodically clear out archived, inactive patient files by scanning the entire file and shredding them. Set a policy that indicates after how many months or years of inactivity the files will be scanned and shredded. (Follow HIPAA guidelines for shredding protected health information.)

3) Don't include insurance information in your patient files, such as copied explanations of benefits (EOBs). These should be filed in a daily bundle style packet at the end of a shift with other important documents like sign in sheets, deposit tickets, the day's posted EOBs, credit card vouchers and other daily documents. These should never be kept with patient records. Filing these by date, then periodically archiving after months or years, will save precious space. These can be scanned and shredded as well.

Every practice should have a compliance policy describing how you handle patient records. Add it to your HIPAA or OIG Compliance policy manual. Here is a sample template to get you started.

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