The most important reason for retaining medical records is to share information on a patient’s care with other healthcare professionals. The COVID-19 pandemic and increased inpatient telehealth services have emphasized the importance of retaining complete and accurate records. Retaining well-maintained patient records helps medical professionals ensure continuity of care and protect against any future professional liability claims. The availability of accurate records also provides protection against licensing board complaints and peer review inquiries and can help when responding to investigations by governmental compliance agencies. The potential for billing audits by the Centers for Medicare and Medicaid Services (CMS) or commercial insurance carriers provides further motivation to create and store complete documentation.
Importance of Retaining Medical Records
- Continuity of care: As discussed earlier, the most important reason for retaining medical records is to provide information on a patient’s care to other healthcare professionals. An accurate record of an individual’s presenting complaints, signs, and symptoms derived from a careful physical examination, any differential diagnoses, and the treatment plan helps to optimize patient well-being and promote more effective continuity of care.
- Continue appropriate treatment: Without the patient’s record, a medical professional might not be able to show that the treatment was appropriate and that it met the standard of care. Simply relying on the practitioner’s testimony of general habit and practice to show that the standard of care was met, without supporting documentation to establish the treatment that was rendered, often fails to convince a jury that the treatment the patient received was consistent with professional standards.
- Prove medical necessity: Patient records also play an important role in proving medical necessity. Billing audits require clear documentation demonstrating the medical necessity and the nature and scope of the services provided.
- Avoid malpractice action: A well-documented record increases support for the provider’s defense in the event of a malpractice action. Entries made in the record at or near the time of the event are regarded as highly reliable evidence in subsequent judicial procedures. The record and progress notes, key evidence in a professional liability action, are critical to helping refresh the provider’s recollections of events that might have occurred years earlier and to establish facts at a time when no conflict or other motivation influenced the circumstances at issue.
- Maintain quality of care: Medical records are also important in establishing the quality of care rendered in the event of a professional licensing board or peer review inquiry. Patient complaints are often based on an individual’s mistaken recollection of events or on a failure to understand the course of treatment or adverse consequences involved in the dispute.
Applicable Laws
Federal laws make it mandatory to retain complete and accurate medical records for medical practices. For example, the Medicare Conditions of Participation (CoP), require hospitals to retain records for five years (six years for critical access hospitals), whereas Occupational Safety and Health Administration (OSHA) requires an employer to retain records for 30 years for employees who have been exposed to toxic substances and harmful agents.
Federal legislation such as Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health (HITECH) have also added new requirements for medical and dental records. HIPAA privacy regulations, for example, require that documents created in compliance with the Privacy Rule, such as policies, procedures, and accountings of disclosures, be retained for six years from when the document was created, which follows the federal statute of limitations for civil penalties. The healthcare professions have primarily been regulated by the states rather than by a federal oversight agency. As a result, record retention laws and regulations differ from state to state, so it is important to check and follow state requirements.
To summarize
As discussed, you must follow your state’s specific guidelines or laws. Where no statutory requirement exists, we recommend the period for retaining medical records as Adult patients, 10 years from the date the patient was last seen; Minor patients, 28 years from the date of birth; Deceased patients, five years from the date of death. Once a record has been destroyed, it is difficult, if not impossible, to defend a case. We encourage medical and dental professionals to consult with their legal counsel regarding how the law in the jurisdictions relevant to their practice has been interpreted by the judicial system. You can also check any signed managed care agreements or contracted healthcare plans to ensure compliance with the record retention requirements of those agreements.
MedicalBillersandCoders (MBC) is a leading outsourcing medical billing company providing complete revenue cycle services. The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. We shared all this information for reference purposes only, the ultimate decision should be taken in accordance with the applicable laws of the jurisdiction in which the care is rendered.
FAQs
1. Why is it important to retain medical records?
The primary reason for retaining medical records is to ensure continuity of care by sharing patient information with other healthcare professionals. Accurate records also protect against professional liability claims, licensing board complaints, billing audits, and peer review inquiries.
2. How do medical records help prove medical necessity in billing audits?
Medical records play a critical role in proving medical necessity during billing audits by providing clear documentation that demonstrates the nature, scope, and necessity of the services provided. This is essential for compliance with Medicare, Medicaid, and commercial insurance requirements.
3. What is the role of medical records in avoiding malpractice claims?
Well-documented medical records serve as key evidence in defending against malpractice claims. They provide reliable proof of the care provided and help refresh the provider’s memory in legal proceedings, particularly when events occurred years earlier.
4. What are the federal requirements for retaining medical records?
Federal laws, such as HIPAA and HITECH, set specific requirements for retaining medical records. For example, HIPAA requires that certain documents be kept for six years, while OSHA mandates that employee exposure records be retained for 30 years.
5. How long should medical records be retained for adult, minor, and deceased patients?
- Adult patients: 10 years from the date of last visit.
- Minor patients: 28 years from the date of birth.
- Deceased patients: 5 years from the date of death. Always consult state-specific laws and regulations to ensure compliance.
