Do you still have paper records in your practice or facility? According to The Office of the National Coordinator for Health Information Technology, as of 2017, almost 86% of office-based physicians adopted a form of electronic health records and 96% of all non-federal acute care hospitals used certified electronic health technology. Even so, most providers still have, use, or store paper records. Have you ever wondered what to do with all of your practice's paper records?
Here are guidelines and considerations for retention and destruction of paper records:
1. Federal Law and Medicare. Ten years is the upper limit for record retention most often cited, but this doesn’t mean you have to keep the records in paper form. For fraud and abuse claims, the Civil False Claims Act, 31 U.S.C. § 3729, provides that in no event may such an action be brought more than 10 years after the date on which the violation is committed. In addition, the retention period for Medicare managed care provider records is also 10 years. However, a medical record can either be in its original form or in a “legally reproduced form” which may be an electronic reproduction, according to the Centers for Medicare and Medicaid Services (CMS).
If you plan to keep electronic copies of records and destroy the paper versions, be sure that you have good quality control measures in place. The Medicare General Information, Eligibility and Entitlement Manual, Pub. 100-01, Ch. 7, § 18.104.22.168 states that imaging can be used to replace paper documents “only when the image will be identical to the paper . . . .” A provider “must retain the paper records until their certification/quality assurance process . . . has been completed and the imaged information . . . is verified as an identical replication of the paper document. Only then can the paper records be destroyed.”
2. State Law. The statute of limitations in your state for malpractice claims can help you decide how long to keep paper records, and you may even find guidance about what form the records should be in under your state’s evidence laws. Also, state licensing boards for your providers may have guidance on record retention and in what forms.
3. Managed Care Contracts. Check your managed care contracts. As noted above, Medicare has a retention period for managed care provider records, and other payors may have an explicit provision in their agreements or in their policies as well.
4. Liability Insurance. Before destroying or scanning paper records, check with your malpractice carrier for record retention requirements. Your insurer may have a policy regarding record retention and conversion of paper records when a provider implements an electronic medical records system.
The items mentioned above should serve as a starting point for record retention and destroying paper records. This topic is broad, but will hopefully help you review your record retention policy or implement one, and provide you with the basic considerations on how to answer the question of what to do with all of your paper records.