Crafting a Medical Records Retention Policy in the New Electronic World

John Lynn

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A healthcare provider’s medical records retention policy used to be determined by state record retention laws or the organization’s own culture. Generally speaking, risk-averse organizations would shred old paper charts as soon as state laws allowed it. Rural and research organizations, on the other hand, were more likely to make the case that no paper chart should ever be destroyed.

The New Records Retention World

There are still some ongoing debates between those who fear liabilities associated with old charts and those who want the data for research and ongoing care, but most organizations have determined where they stand on the records retention policy spectrum. The problem, however, is that electronic health records (EHRs) and other health IT software have created a new world when it comes to records retention and leveraging medical data. As such, most healthcare organizations would do well to reevaluate their records retention policy in the new world of electronic data.

Healthcare organizations should ask the following questions when evaluating their retention policies: Do electronic charts need to be destroyed after seven years or another specific time period mandated by law? Do the reasons the organization used to destroy paper charts still apply in an electronic world? For example, many organizations destroyed old paper charts to free up storage space. Millions of electronic charts can now be stored on a thumb drive, so storage space is no longer as serious a consideration. In that case, does it make more sense to convert paper charts to digital records?

A Future Need for Historical Data

Another important question is whether the organization should simply retain electronically generated health data indefinitely. Many organizations chose to destroy paper charts to avoid liability, but as healthcare starts leveraging more data to inform care, is there more liability in not having historical data on a patient than in retaining old medical charts? It is not hard to imagine the day when having the full health history of a patient will be the standard of care. The industry is not quite there yet, but it is getting close.

Any records retention policy must take into account the modern electronic environment, regardless of the details of individual organizations’ policies. Once these plans are established, organizations need to work with their EHR and other health IT vendors to ensure their software supports their specific security and retention needs. A policy to delete medical records that are seven years old is no good if the EHR software does not support the deletion of charts. Healthcare organizations need to collaborate with vendors from day one if they want to ensure their software enables their records retention requirements.

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