- Identifying Standard Agencies, Laws, and Regulations
- Learning HIPAA Controls and Compliance Issues
- Learning Rules of Record Retention and Disposal
- Learning Legal Best Practices and Documentation
- Chapter Summary
- Key Terms
- Acronym Drill
- Review Questions
- Practical Application
This chapter is from the book
This chapter is from the book
This chapter is from the book
Learning Rules of Record Retention and Disposal
Documentation requirements are defined by HIPAA, but some requirements vary from state to state. The state defines how long records must be kept, called record retention. HIPAA defines how records are disposed of and how they are kept in storage (archived). The three types of records are public, private, and legal. All these follow the same rules for retention and disposal.
Types of Health Records
Health information comes in three different types. A patient’s public health record is used for research and to create reports for public health data. For example, if a state requires a hospital to report how many patients are at risk for getting the flu, the public health records are accessible to calculate this information. Figure 3-10 shows the reporting function of an example EHR IS. Public health records are not intended to connect individuals to their health records.
A private health record is the health record created and maintained by an individual. The benefit of a private health record is the individual is completely aware of all healthcare received and is available to the individual no matter where she may be a patient. A private health record is great for chronically ill patients or for an individual who is a guardian of another individual.
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Figure 3-10 The reporting feature of an EHR IS provides a list of patients at risk for the H1N1 virus.
Photo credit: http://www.practicefusion.com
An individual may keep a private health record in any format she prefers. She may simply place her health records in a file folder on her computer or move it to a jump drive for added security and mobility. She might decide to keep her health records with a web-based service designed for private health records. The benefit of using a web-based service is that many healthcare providers can access and easily format the data from these services for the HIS used at the facility with the permission from the individual.
A legal health record is the health record created by healthcare providers. The regulations for legal health records are set by the state and healthcare organization with a few basic standards set by the federal government. The legal health record can be requested by the patient or legal services. For example, if a patient brings up a lawsuit due to received healthcare, the court might need the legal health record to know what was charted in the patient’s health record.
Record Retention
HIPAA sets a minimum timeframe for record retention of six years and for two years after a patient’s death, and Medicare requires Medicare beneficiaries’ records be retained for five years. HIPAA enables the states to create laws to dictate their own policy for record retention so long as the state law meets minimum HIPAA requirements. If a state requires more time for record retention, covered entities in that state must comply with the state law.
States have the freedom to determine how long documents need to be stored before disposal. States retain records anywhere from 6 to 20 years. Some states choose to vary the length of record retention based on resources, type of patient, events during the course of care, or any other stipulation.
When you start a new job, check with your state’s legislature website or ask someone in the medical records department at your facility. For example, if your new job is to implement a new EMR/EHR IS in a hospital, you would need to know how long to program the EMR/EHR IS to retain the health records.
Record Disposal
HIPAA states that record disposal is the responsibility of covered entities. Physical documentation can be shredded, burned, or pulverized. PHI on electronic media is sometimes disposed of by cleaning, purging, or destroying the device. The covered entity is at fault if any physical or electronic PHI is recovered at any point after the disposal of records.
The basic rule when disposing of an electronic device that contained e-PHI is to make sure the data on the device is unreadable, is indecipherable, and cannot be reconstructed. Following are three ways records on electronic media can be disposed of:
- Cleaning the device is when irrelevant data (1s and 0s) is written on the memory several times. This method is considered unacceptable in the healthcare environment by many technicians. The only reason cleaning a device is okay is when the device has never had PHI on it; for example, the gift shop computer or the server used to control HVAC in the facility.
- Purging or degaussing is when exposure to a strong magnetic field is used to purge data from the device.
- Destroying a device is when physical destruction is used to render a device useless. For example, you can drive a nail through a hard drive to make sure no one can recover the data that was once on that hard drive.