Healthcare Leadership and Innovation

Record Retention & Destruction

  • 1.  Record Retention & Destruction

    Posted 10-06-2020 13:10
    Hello community,

    I recently started in a company that has an EHR established, however, they still keep the initial intake for new patients and create paper charts.
    This includes:
    Demographic information
    Consent for examination and treatment
    Patient acknowledgement consent form
    Financial guarantor form
    Release of information/ HIPAA form
    I would like to know if this is necessary if the intake is being scanned into the EHR. The compliance team of the company is hesitant on shredding any original documentation with original signature because auditors might ask to see original documentation (that's been their experience in the past).
    Any feedback or advice would be helpful thanks.

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    Jenniffer Baez, RHIA
    Medical Records Supervisor
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  • 2.  RE: Record Retention & Destruction

    Posted 10-07-2020 09:32

    It might depend on your state rules.   When I was in Indiana, once the paper copy is scanned into the chart, the electronic version becomes the legal medical record.

     

    Wear your mask!   It's the right thing to do. 

    Ruth Heinz, MS,RHIA,CHP

    Supervisor, Health Information Management

    Norton Healthcare

    Phone: (502) 629-3842

    Email: Ruth.Heinz@Nortonhealthcare.org

    Untitled

     






  • 3.  RE: Record Retention & Destruction

    Posted 10-08-2020 08:29
    Jennifer

    I agree with Ruth. Once the information is scanned into the EMR it is the legal medical record. We do keep our scanned documents for 30 days so that if something gets missed we can go back and find it but after that it is shredded. If you don't have a signature log it is good to have. It is a log of all employees who are legally able to make changes, additions, deletions to a medical records - providers, nurses, therapists, lab, imaging, etc. We update ours on a yearly basis that way if an auditor wants to compare a scanned signature to an original they have it. I've never had an auditor ask for it but I have had to use the log on appeals with insurance companies.

    It is double duty if you have a scanned in copy as well as a paper copy and more cause for errors. Not sure about state rules but we follow CMS rules at our facility.

    Thanks.

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    Beth Kosman, RHIT, CCS, CCS-P
    HIM Director/Privacy Officer
    Compliance Officer
    Ringgold County Hospital
    Mount Ayr, Iowa
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