Confidentiality, Privacy and Security

​unsolicited records and patients who have not been seen recently

  • 1.  ​unsolicited records and patients who have not been seen recently

    Posted 07-15-2019 11:39

    Hello -

    Does anyone have a sample policy or process that speaks to unsolicited ER records for patients that have not been seen in years by our provider?  Is there a best practice for whether to scan them into the record or send them back to provider?

    Our scenario is we have ER's sending records to us for patients that have not seen our physicians in three or more years.  From a compliance standpoint, I am trying to figure out what to do with them.

    Thank you


    Sarah Jackson
    Compliance Manager

  • 2.  RE: ​unsolicited records and patients who have not been seen recently

    Posted 12-04-2020 11:32
    We are in the same predicament. We received records for a person who is not our client but apparently the client directed the hospital to send their records to us (behavioral health) but it's been about 3 months and they haven't been opened as a client. How long should we hold them or should we return them to the hospital? Does anyone have a policy example? Thank you

    Aurae Beidler MHA,RHIA,CHPS,CHC
    Compliance/Privacy Officer

  • 3.  RE: ​unsolicited records and patients who have not been seen recently

    Posted 12-05-2020 06:36
    I don't have a policy template for that part of retention, but my guiding principal has been, and this was determined with a healthcare attorney, that you have complete control over how you structure your retention and then destruction of those types of records. There is no time frame that applies. Write it up and you think prudent and follow the policy, modify it later if you find you need to for some reason, but follow your own policy what ever it is.

    If a patient brings you records you don't want, because they won't get reviewed, the attorney used to joke his Mom carried boxes of records to each physician and they didn't want that many old records, so his advice was not to take them. Either don't accept them or have in policy what you accept and put into the record and what you return to the patient. If you take them they either go in the record or you have to use proper destruction.

    Make a log for all such records that either are brought or sent in and their disposition, including if they were incorporated into the patient's record.

    Kelly McLendon, RHIA, CHPS
    Managing Director
    CompliancePro Solutions

  • 4.  RE: ​unsolicited records and patients who have not been seen recently

    Posted 12-05-2020 17:00
    Thanks Kelly! I appreciate it and always nice to hear from you. 

    Happy Holidays!

  • 5.  RE: ​unsolicited records and patients who have not been seen recently

    Posted 12-10-2020 11:29
    Here is what we have on this:





    Key Functional Area:    Medical Record Operations

    Original Effective Date:     September 1, 2017

    Effective Date of Current Revision:   September 1, 2017   effective – January 1, 2014 ]

    Review/Revision Date(s):  May 17, 2018; November 4, 2020

    Scope: All DCMC HIM Sites – Including Off-site Clinics

    Policy Number:  HIM-MR-3

    Revision Number:  Replaces Policy:  


    Defined terms are "Capitalized."  Definitions are embedded in or included at the end of the Policy.


    Purpose:   To provide guidance on how to manage advance directive documents and/or other external patient health records received when there is no DCMC patient health record on file.  Note:  DCMC will not create a patient health record for the sole reason to store scanned or paper records from an external source.



    Policy Procedure Statement/s: 


    1. When external documents are received from individuals, healthcare providers or other sources and there is no record of the individual ever being a patient at DCMC, the documents will be managed as follows:
    1. Stamp or write date of receipt on the front page of the documents.
    2. If a legible name and address exists (or can be found) for the individual on the documents, complete attached notification letter and:
      1. Send original to patient; and
      2. Attach copy to documents.
    3. Store documents for six months in a holding area in the HIM File Room in case individual is seen as a patient at DCMC.


    1. After six months of holding, verify individual has not been seen at DCMC and dispose of in a confidential manner.


    Responsible Leader:   Nancy Davis, Director of Compliance & Safety


    Consulted With:   Social Services and Spiritual Services Departments







    Name/DOB/Address of Individual: __________________________________________________________________________




    Dear Sir or Madam:


    Door County Medical Center has received copies of the following healthcare records on you to be maintained in our files:


    • Power of Attorney/Power of Attorney for Health Care
    • Living Will
    • Other Advance Directive-Type Document
    • Copies of Health Records from Other Doctors/Hospitals/Healthcare Providers
    • Insurance Correspondence
    • Other: __________________________________________________________


    We strive to have a complete and accurate health record for every patient who receives services at Door County Memorial Hospital.


    Unfortunately, we have no record of you ever being seen at Door County Medical Center.  Without an available patient health record for you on file, we have nowhere to "attach" the records that were sent to us.    We cannot create an account/patient health record without having services provided to you as a patient.


    We will maintain the records we have received in our files for six months.   If at the end of that period you have not received services/established a patient health record, we will destroy the documents in a confidential manner.





    Health Information Management Department

    Door County Medical Center


    Copy:   Attached Copy to Records and Hold Six Months

    Nancy Davis, MS, RHIA, CHPS
    Director of Compliance & Safety
    Door County Medical Center

  • 6.  RE: ​unsolicited records and patients who have not been seen recently

    Posted 12-10-2020 11:49
    Thank you Nancy! This is exactly what I needed. I appreciate everyone's help.


    Aurae Beidler

    "Happiness is neither virtue nor pleasure not this thing nor that but simply growth. We are happy when we are growing." - William Butler Yeats

  • 7.  RE: ​unsolicited records and patients who have not been seen recently

    Posted 12-11-2020 07:24
    Good Morning All!

    I read with interest Nancy's post concerning what to do with records that probably in the first place shouldn't have been sent or received. This is not my field of expertise but I am curious to know if all this effort is part of a wasted resource trail. What I mean is, why would a facility receive records for an individual who has not received services at the facility? Is this in light of the individual becoming a patient for the facility at a future time? Or had the individual listed a provider who is now a provider at the facility and the individual is following a particular provider?

    I'm really trying to understand how this happens and why resources are given to this type of holding an individual's PHI/records when I think there could be a legal aspect given if there was ever a natural disaster or some other type of slippage of information getting into the wrong hands?

    Any industry references I would be given on this topic would be very much appreciated or even general insight would satisfy the interest with this topic.

    Nancy, I always look forward to the wealth of information of your contribution in this forum!

    Kelly Randell
    DRG Analyst
    [G2 Corporation]

  • 8.  RE: ​unsolicited records and patients who have not been seen recently

    Posted 12-11-2020 07:56
    Thanks Nancy, this is great!.

    Stacey Goodenough
    Manager of Medical Records / Privacy Officer
    Wayne Memorial Hospital