Health Information Technologies & Processes

Record Retention Dispute

Lori L. Richter, Healthcare Management,Leadership,RHIA,CHPS,MA,CPHI08-02-2018 11:08

  • 1.  Record Retention Dispute

    Posted 07-06-2018 10:42
    ​Hello - We are trying to put a plan in place to tackle this massive record destruction project and, just as we are ready to begin, we are getting mixed responses regarding what/when we can destroy records.   Everything I have read is recommending that we destroy charts based on 10 years from last date seen.  We need clarification on what that means:
    1.  If a patient is still active but has records that are more than 10 years old, do you destroy those older records or wait until the patient is no longer active and destroy all records based on 10 years from the last date of service?
    2. What if the patient is being treated in different programs within our facility?  For example, a patient was in our Inpatient hospital 12 years ago and entered our Nursing Home 10 years ago and is currently a resident, would you destroy the hospital records because they are past the retention period?

    We have been getting many mixed responses to our retention and are trying to clear out 45+ years of records.  It has now been suggested that if we have records for a patient who is disabled, these should be kept for up to 20 years (supposedly in WI Statute 893.16, though I've not been able to locate specifics) and Skilled Nursing records should NEVER be destroyed at all.  I was referred to the WHIMA Legal Resource Manual, which I have discovered is now no longer available.

    Any suggestions - from anyone - would be greatly appreciated!
    Thanks.

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    Carol Rich
    Health Information Supervisor
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  • 2.  RE: Record Retention Dispute

    Posted 07-09-2018 05:15
    Based on the 10 year question, yes a record may be thinned out. If a patient has multiple visits and some are older than 10 years, you may destroy them.

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    Victoria Maans
    HIM Manager/Privacy Officer
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  • 3.  RE: Record Retention Dispute

    Posted 08-01-2018 11:46
    ​I am also curious on the 10 years from last date seen.  The way I took it, if the patient has been seen in the last 10 years, we have to keep all of their records.

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    Ashley Friedrich
    HIM Director & Privacy Officer
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  • 4.  RE: Record Retention Dispute

    Posted 08-01-2018 12:11

    We are an LTCH (inpatient only) and use 10 yrs from date of discharge.

    Donna

     






  • 5.  RE: Record Retention Dispute

    Posted 08-02-2018 11:08
    ​Your questions are spot on. What I have found across our multiple states my entity does business in, the retention schedules and very specifics are state specific. NE for example is retained for 10 years (for adults, minors has more specificity) and each account is separate (so date of discharge per account not per MRN or patient). Whereas another state is set up that if the patient has been seen at all the entire record (and every account within) must be maintained through retention, which wouldn't go into affect/clock start ticking until very last date seen.

    GOOD LUCK this is a ginormous work product and I applaud you for doing this! Lori

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    Lori Richter
    OneCare EHR Compliance Director
    Catholic Health Initiatives
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  • 6.  RE: Record Retention Dispute

    Posted 08-07-2018 10:19
    Our retention period is 10 years from the last date of service for adults and 10 years from the age of majority for children, which is essentially age 28. I would keep ALL records for 10 years after the last date of service. Especially if the hospital and LTCH are owned by the same company.

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    Ta-Tanisha Ingram, MSM, RHIA, CHPS
    Medical Records Administrator/District Privacy Officer
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  • 7.  RE: Record Retention Dispute

    Posted 08-07-2018 12:18

    To add some confusion – I have had some issues with records retention once we implemented an electronic health record.  We still have some charts that are on paper, and we scan these into the EHR, and our older paper charts periodically  go to an imaging company and they scan it.    With the imaging company, we still have access to the documents, but not directly in our EHR.  The question now is, is it okay to destroy the paper charts before the 10 year waiting period, because the documents are now actually permanently located in the EHR.  I would welcome any additional thoughts.

     

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  • 8.  RE: Record Retention Dispute

    Posted 08-07-2018 12:20

    Hi Karen, I would say yes. We have a policy that we only hold on to the paper charts for 90 days after being scanned into the EHR. There is no need to keep the paper records as your legal record is what is in your EHR. Plus you get to save money on storage.


    Thanks,
    Karla

     






  • 9.  RE: Record Retention Dispute

    Posted 08-07-2018 13:04

    Thanks, Karla.   I think we have just had a difficult time letting go of our paper charts, and trusting the EHR!

     

    Karen Evans

    HIM Ddirector

    Yuma District Hospital & Clinics

    1000 W. 8th Avenue

    Yuma, Colorado 80759

    kevans@yumahospital.org

    970-848-4626

     

     

     

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  • 10.  RE: Record Retention Dispute

    Posted 08-07-2018 13:21

    I hear you. This is why we do 100% quality review on all our images. We just started destroying two years ago after never destroying ever before. I was very nervous but our Corporate Compliance officer and General Counsel felt comfortable with letting go.

     






  • 11.  RE: Record Retention Dispute

    Posted 08-08-2018 12:46
    ​Hi Karla,
    Have you started destroying any records located in your EHR?  Do you plan to?

    Thanks,
    Teri

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    Teri Smith
    Health Information Administrator
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  • 12.  RE: Record Retention Dispute

    Posted 08-09-2018 10:50

    Hi, not yet. I would like to get there. That is a bigger conversation with my legal department I plan on having soon.

     






  • 13.  RE: Record Retention Dispute

    Posted 08-10-2018 12:15
    ​Thanks Karla.  I'm curious to see how things turn out for you.  To the best of my ability, I've found out that our EHR does not retain ANY info when a patient chart is deleted (so I'm told).  Therefore, no MPI.  Looks like we will no longer be destroying our records.

    Teri

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    Teri Smith
    Health Information Administrator
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  • 14.  RE: Record Retention Dispute

    Posted 08-10-2018 12:48

    We would never delete the record from the MPI, hopefully we can purge electronic data. Not sure what the possibilities are with Meditech- they cannot do much of anything! I can let you know. Shoot me an email at kviruet@valleyhealth.com and I will keep you posted.

    Karla

     






  • 15.  RE: Record Retention Dispute

    Posted 08-07-2018 12:41

    Thank you all for your input.  I believe this is helpful...

     

    Carol L. Rich, CPC

    Health Information Supervisor

    Health Information Management

    1100 Lakeview Drive

    Wausau, WI  54403

    Phone: 715-848-4473

    Fax: 715-842-2017

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